Tuberculosis and the Creative Spirit

Last Wednesday I visited Abu Anga Hospital in Omdurman, which is the only specialist centre for managing ‘Multi Drug-Resistant’ tuberculosis (MDR-TB) in Sudan.

I travelled by bus, which can get rather painfully hot when stuck in the morning traffic. But buses do give you a chance to see many examples of everyday Sudanese ingenuity at work. Today for instance, as I got to my seat, I stepped over a large hole in the floor resourcefully covered with wooden planks and several dozen nails, so that you could barely even see the road below anymore. Another little example – as the conductor started to collect fares, he ran out of pockets and hands and so started to put coins in his ears. Every inch of space on buses is used. An extra row of seats on hinges fold up and down to fill the aisle, so that passengers are packed in like sardines.

You can get on and off the bus at any point. To get the driver to pull over, you just click your fingers and make a “kssss kssss kssss” sound – as if he were a huge cat (maybe if I try to tickle him I can get a journey for free?). Indeed, for some reason that I haven’t yet discovered, many bus drivers seem to wear furry, leopard-print slippers. There are hundreds of these vehicles on Khartoum’s roads, bus-sized tins of sardines driven by huge furry cats.

Further inspired opportunism isn’t hard to find. Driving past one street corner in central Khartoum, you can see what is very clearly a hearse (i.e. a car with a large glass compartment for displaying a coffin on the way to a funeral). It now rests there on the pavement for evermore, and has been plastered bizarrely with blue and yellow advertisements, plus full colour photos, for a male baldness therapy. But my favourite example of this creative spirit, though unrelated to buses or roads, is the pot of strawberry jam in my room. The maverick designers have created a very colourful illustration on the label, which shows not a single strawberry, but does include figs, bananas, mangos, and (my new favourite fruit) carrots.

Whilst this kind of innovative approach to life can be very handy, when it comes to tackling tuberculosis then good intentions and creativity can create problems rather than solutions. 

The bit about Tuberculosis                                                                                             

Tuberculosis is common in Sudan, out of a population of 44 million people there are around 25 000 new cases every year and a total of about 82 000 cases at any one time (WHO 1). In the UK, for comparison, out of a population of 62 million people, there are just over 7 000 new cases a year, with a total of around 9 600 cases at any one time (WHO 2).

Clinics at both Soba Hospital and the Omdurman Hospital for Tropical Diseases have been full of patients with tuberculosis. The bug – mycobacterium tuberculosis (M. TB) – may infect many different parts of the body, and so patients can present to doctors with symptoms involving anything from the head, neck and spine, to the chest, abdomen and skin.

TB care is co-ordinated by the National TB Programme, based in Khartoum. Treatment for patients should be completely or partially subsidised, and there are very clear World Health Organisation (WHO) guidelines for the use of anti-tuberculous drugs.

(Any readers with a slightly shaky interest in TB management close your eyes now for a couple of paragraphs…)

Patients who fall into ‘Category One’ (i.e. patients newly presenting with tuberculosis) receive first-line treatment (two months of HRZE and then four months of HRE – see below for abbreviations).  If all goes well, patients can be completely cured and symptom-free after six months.

However problems arise when patients present with tuberculosis for a second time, after having started a course of treatment at some point in the past. There are generally three reasons for this:

1) Default – The patient did not complete the full course of medication (i.e. they stopped too early) – for example because they start feeling better, or cannot meet the costs of treatment, or supplies of drugs run out.

2) Relapse – the patient completed the treatment course and was cured, but has been re-infected.

3) Failure – the treatment failed to kill the TB bugs

In re-presenting patients with these backgrounds, the M. TB are more likely to have developed resistance to some of the first-line drugs. They then fall into one of two treatment pathways. Patients who (1) default or (2) have relapsed are deemed to be ‘Category 2’ and are prescribed an adapted regimen including streptomycin (see WHO 2010b).  

However if (3) first-line treatment has failed, then there is a strong possibility that the patient is infected with Multi Drug-Resistant Tuberculosis (defined as proven resistance to H+R). This can be investigated with Drug Susceptibility Testing (DST) of the TB bugs, though this is expensive and can be time-consuming. Where DST is not available (like in Sudan, where it is normally used only for research purposes), such patients are assumed to have MDR-TB, and begin treatment with second-line drugs (see note below for more detail on these).

This second line regimen is far more expensive, lasts for longer, and has more potential for causing serious side-effects in the patient. Financial help is available from a WHO subsidiary called the Green Light Committee (GLC), subject to some fairly stringent criteria to do with the use and monitoring of these second-line drugs. Considering the difficulties that many countries face in applying international standards even for first-line drugs, it can be a huge challenge to satisfy conditions for GLC funding. In such countries, the spectre of an MDR-TB epidemic is alarming.

In Sudan, data from 2009 shows that a quarter of previously-treated patients were confirmed as having MDR-TB, much higher than rates in neighbouring Ethiopia (12%) or Uganda (13%) (Eldin et al 2011).  This is where we come back to the beginning and the ‘creative spirit’.

(…and open your eyes again)

TB drugs are not like buses, you cannot get on and off when you want, you must stay on for the full ride (around 8 months for first line drugs). If part of the drug regimen is missing, it cannot just be tacked over and forgotten about. Each drug acts in a slightly different way, and if one of them is missing, then the M.TB may survive and develop resistance to the first line drugs.

Unlike my strawberry jam label, patients need to be very clearly informed about what they are about to consume. TB drugs can have a range of nasty side-effects. Doctors need to educate their patients, to steel them against coming difficulties, and advise them to continue taking their medications and report any side-effects.

But it’s difficult. Poverty and a lack of education are powerful stimulants to ‘creativity’. If you get some side effects, like hepatitis, or losing your colour vision, then without free and easy access to a doctor and some treatment it’s rather tempting to stop taking your TB pills – particularly if your cough has cleared up.

If they have run out of a particular TB drug at your local clinic or district hospital, or it is only available upon payment (as opposed to being free), then both patients and doctors may try to ‘adapt’ drug regimens to make the best of what they have. This has been a problem in Sudan, with patients being hurt by inadequate private sector regulation (Maalaoui 2008).

Conclusions

So what to conclude? I guess many of the things I’ve discussed here affect people all over the world, not just in Sudan – so maybe this should end with some kind of rallying call for global health. Tuberculosis is not like buses or strawberry jam, and health is not just about pills and doctors. It also involves access to healthcare, income levels, education, private sector behaviour, government regulation, international organisations, guidelines and financial programmes – and that’s all before you get down to the individual, creative level. So it’s not all that simple. It involves structures and processes which can appear very difficult to change, and presents some fairly testing challenges. But with a bit of creative thinking in the right places, surely its possible to get it right?

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Abbreviations:

First line drugs: H = Isoniazid; R = Rifampicin; Z = Pyrazinamide; E = Ethambutol; +/- S = Streptomycin

Second line drugs: These include a parenteral drugs such as amikamycin; fluoroquinolones, such as moxifloxacin and levofloxacin; oral bacteriostatic agents such as ethionamide or cycloserine; and ‘group 5’ drugs such as clofazamine and imipenem (see WHO 2011, especially p19, and WHO 2010b p84-7).

DST – Drug Susceptibility Testing

GLC – Green Light Committee

M.TB – Mycobacterium Tuberculosis

MDR-TB – Multi drug-resistant tuberculosis

WHO – World Health Organisation

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Documents:

Eldin et al (2011) Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs. BMC Infectious Diseases. 11: 219   – www.biomedcentral.com/1471-2334/11/219/

Maalaoui, N. (2008) Strengthening TB Drug Management in the Sudanese National TB Control Program: In-Depth Review of TB Drug Management – http://pdf.usaid.gov/pdf_docs/PDACO436.pdf

 

WHO (2011) Guidelines for the programmatic management of drug-resistant tuberculosis (2011 Update) – www.who.int/tb/challenges/mdr/programmatic_guidelines_for_mdrtb/en/index.html

 

WHO (2010a) The human face of tuberculosis in Sudan – www.emro.who.int/dsaf/dsa1077.pdf

 

WHO (2010b) Treatment of Tuberculosis: guidelines for national programmes. 4th edition

www.who.int/tb/publications/tb_treatmentguidelines/en/

 

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Webpages:

 

Green Light Committee (WHO subsidiary for tackling MDR-TB and XDR-TB) – www.who.int/tb/challenges/mdr/greenlightcommittee/en/

 

Sudan: Stop TB website – Eastern Mediterrean Regional Office – (Information about the National TB Programme).

www.emro.who.int/sdn/programmes/stop-tb-sudan.html

(WHO1) WHO Tuberculosis statistics for Sudan: https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=SD&outtype=html

(WHO2) WHO Tuberculosis statistics for Great Britain and Northern Ireland:https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=GB&outtype=html

Beans, Grains and Madura Foot: Tasty Food, Tasty Medicine

I’m eating quite alot of beans at the moment.

‘Ful’ is the most widely-eaten meal in Sudan. It is made from black beans, cooked until they are soft, and then eaten with cheese, salt, onions and bread. Fasulya is made from white beans, and is cooked in the pot with some meat on the bone for flavour. They, along with some saucy dishes of potatoes, courgettes and peppers form the basis of diet, supplemented by a rather delicious range of fruit juices and the odd half-chicken.

There are many restaurants around Khartoum, serving a range of Sudanese, regional (as in Egyptian, Lebanese etc) and Western food. However due to burgeoning US sanctions, no American companies (like MacDonalds) can set-up shop here.

Being so ‘ful’ of beans (ho ho ho) can be rather useful for long ward rounds. I’ve seen a number of very interesting clinical cases over the past couple of weeks. Briefly, I’ve seen patients with pellagra (vitamin B6 deficiency with the clinical triad of dementia, diarrhoea and dermatitis); with Guillain-Barre Syndrome where polio and mercury- and lead-poisoning from mining were real differentials; with severe, quinine-resistant falciparum malaria and acute renal failure; with a bad drug-reaction to anti-malarial quinine therapy; and with complicated portal hypertension, resulting in different patients from chronic hepatitis, schistosomiasis and alcoholism. At the clinical meetings, I’ve also heard two interesting case presentations, firstly of a patient diagnosed with Churg-Strauss Syndrome (in the textbook this is late onset asthma, eosinophilia, small vessel vasculitis and a range of other potential features), presenting with joint pain, purpuric rash, dyspnoea, peripheral neuropathy, loss of vision and fever. The second case was a patient brought in from Jezira State, south of Khartoum, with DIC (blood clotting inside the blood vessels) resulting from a cobra bite. All these  cases were of  patients on the general medical ward.

I also spent some time at a specialist institute, the Mycetoma Research Centre, at Soba University Hospital. Mycetoma  is also called Madura Foot, named by British physicians in the Indian city of Madurai, Tamil Nadu State. It is found across the world in the ‘Mycetoma Belt’, stretching around Brazil and Mexico, through Africa and Arabia to India and South-East Asia.

It is a progressive, granulomatous inflammatory disease caused by particular species of bacteria (actinomycetes) or fungi (eumycetes). It still most commonly affects patients’ feet and legs since the most common route of inoculation is via a thorn, carrying the bacteria or fungi, piercing the skin.

It presents as a clinical triad of a painless, subcutaneous (under the skin) mass, sinus formation and the discharge of yellow and red (actinomycetoma) or black (eumycetoma) grains. As it is painless, many patients present relatively late (i.e. several months or even years after inoculation). This can lead to devasting consequences, as the mycetoma may spread beneath the skin and destroy deeper structures such as bones. Following evidence-based management guidelines developed at the centre, patients have a set of diagnostic and staging investigations and may then undergo medical (taking medicines) and surgical (cutting bits out or off) therapy. Over months, patients can make a full recovery, although recurrence rates are high.

Both the Mycetoma Centre at Soba, and the Institute of Endemic Diseases at the University of Khartoum conduct  ground-breaking, cutting-edge research in their respective fields – fields which are comparatively neglected in other, richer countries with different burdens of disease. They are staffed by well qualified, highly motivated and internationally published and respected scientists and clinicians.

But a small footnote to this is the effect of the unilateral US sanctions, renewed annually by the US Senate, despite promises to repeal them after the signing of the peace agreement in 2005. These sanctions do not just prevent MacDonalds from doing business here, but also prevent a spectrum of American industries, including scientific, technological and manufacturing companies from engaging in Sudan. As is so often the case, the sanctions are hurting the wrong people. That’s not cool beans.

——-

Picture Credit: http://pmj.bmj.com/content/75/889/671.full – Akhtar, M., Latief, P. (1999) Actinomycetoma Pedis. Postgraduate Medical Journal (75) 671 

Fahal, A. (2006) Mycetoma: Clinical Monograph. Khartoum University Press. Sudan

Manson, K. (23 July 2012) US Sanctions take toll on Khartoum. Financial Times.

Institute of Endemic Diseases, University of Khartoum – http://www.iend.org/

Mycetoma Research Centre, Soba University Hospital – http://mycetoma.uofk.edu/

Storm clouds and CT scans (and some food puns to chew over)

My Friday evening this week was spent in a seminar room in a Khartoum hospital, sheltering from the thunder and lightening outside, and listening to a presentation on radiology and orthopaedics.

These first few roasting weeks have sometimes left me looking like a tender young lobster who has fallen into some strawberry ice cream (so yes indeed, exotic AND delicious). Even though I’ve now become a little more used to the heat and the glare, such a dramatic change in the weather was quite fun. Huge storm clouds blocked out the sun, lightening stretched from horizon to horizon, rumbling thunder drowned out the traffic. On the road towards the university, wind whipped up dust to fill the air (plus eyes, ears, nose and mouth), and just a few rain drops fell.

So instead of spending the evening being fried and battered (by lightening, wind and sand), we (the three other international elective students and me) sped off to a hospital to learn about bones on a radiological plate. The lecture was delivered (in English) by a Sudanese radiologist recently returned from working in Britain. It explored ways in which radiology can aid orthopaedic surgery, focusing on knee and back problems. I’m including the event in this blog just because it was interesting just how little seems to change between medical contexts. Indeed, in many ways the session was identical to every clinical meeting I have attended in the UK (although there were a few differences).   

The audience was arranged around a conference table, with the presentation projected onto the wall at the far end of the room, just as it might be in the UK. The senior professors and consultants, dressed in white jellabiyah (ankle length gown) and imma (turban) were sat around the table, with the juniors spread out behind on both sides.   The presentation itself (on powerpoint of course) was about an hour long, during which the row of turbans in front of me bobbed and shook at significant points (just as the front-row of heads do in the UK).

Afterwards came the questions. It seems that senior clinicians throughout the world develop their own tried and trusted habits, techniques and theories – their own ‘flavours’. ‘Question-time’ is a chance to share these favourite flavours, to give everyone a good long taste. And, just as in the UK, there is always some culinary disagreement, leading to more bobbing or shaking and a second round of tasting. The dessert, after all that, was two presentations from the pharmaceutical companies sponsoring the event.

There were also some interesting observations about the way in which the Sudanese health system is fragmented. There are a large number of different hospitals in Khartoum alone, some public (state-subsidised), some private, some general and others specialising. This has many effects; it results for example in a large number of referrals between hospitals, with little continuity of care and no central patient data system. It also means that for disciplines such as radiology, where large and expensive equipment is involved, very few centres are large enough to afford such equipment, or will use it often enough to make it cost-effective.

I believe that health financing in Sudan is largely private, with patients at both private and public hospitals bearing most of the costs of their care. Health insurance companies and state health insurance also play a growing role. International organisations and mechanisms also support specific vertical programmes or local health facilities, such as the detection and treatment of tuberculosis or leishmaniasis. The balance between patients and profits is often a controversial one in health systems, and I suspect that a study of health financing in Sudan would make for some interesting reading (if anyone knows of any then please get in touch!).

So altogether, a stormy appetiser, some tasty morsels and plenty of food for thought!

Pete

‘Khartoum Burns’: What’s the score?

Photo: Ashraf Shazly/AFP/Getty Images

We had had plans for Friday 14th September. We (me and the four other international medical elective students, from Czech Republic, Norway and Poland) were going to spend the afternoon on Tutti Island, in the Nile, where you can sit in the leafy shade and drink tea.

But then at around 14:00 (Sudan time) we got a text from a Sudanese friend, “Don’t go anywhere alone today. Let me know if you’re going out”.

We had heard about the 14 minute Youtube video that had already sparked events in Libya and Egypt, and so assumed that perhaps today, the first day of the weekend, when everyone attends the mosque for Friday Prayers, there might be some kind of protest in Khartoum.

So we cancelled our plans, spent the afternoon out of sight in the Faculty of Medicine’s open-air cafe, and kept an eye on the news headlines. These did their utmost to out-do each other in the ‘shock-horror’ stakes. “Embassies burn in Khartoum”, “5,000 march on the US Embassy”, “Send for Lord Kitchener”, or whatever they were. Today (Sunday 16th and the first day of the working week here) there still seems to be significant confusion about the chronology of what happened, but from reading reports in the Khartoum and international press, and from speaking to different people here, it seems that this is what happened.

After Friday prayers, around 5,000 people (exactly and approximately) congregated outside the US Embassy. They arrived in buses, organised by ‘no-one-quite-knows-who’. The US embassy has been relocated in the last few years, so that it is no longer in central Khartoum, but about 20-30 mins drive outside it and well past the last houses on the outskirts (on the road to Soba Hospital where I am based). Hence the need for buses. The embassy itself is a long way back from the main road, and looks pretty formidable from a distance.

It was reported that ‘the mob’ gathered in ‘the square’ outside the embassy and started burning things. I drive past ‘the square’ every day at the moment on my way in and out of Khartoum. It would be more accurate to call it ‘a field’, as it has nothing in it except some dirt and some dust. It is lined on the main-road side by half-buried car tyres, presumably to discourage attempts at parking. Driving past this field on the morning after, I saw a boy poking some half-buried wires with a stick. So it would seem that these were the fuel for the fires of Friday afternoon.

It’s hard to say what exactly happened, as reports are rather thin and contradictory, but people here seem to agree that around 250 Sudanese security personnel were stationed there, that tear gas may have been used, and that three Sudanese men were killed in the course of the day.

So after some time at the US Embassy, this crowd got back on their buses, and shuttled into central Khartoum, where a number of other embassies reside. They alighted at the German Embassy – a move that neither the international media, nor our Sudanese friends could explain that afternoon. It seems that the Sudanese security services were also wrong-footed, as here the more reckless, violent elements enjoyed some success. They breached the compound walls, lowering the German flag and raising a black one in its place, smashing windows and starting a fire inside. Moving on to the UK embassy next door, a number of men again apparently scaled the wall, but did not enter the building itself (perhaps the security forces were present in greater numbers by this time?).

What seems clear is that these events were very different to those in Libya. In Khartoum, there was no well-armed, well-organised attempt to kill and destroy, or even apparently to send any kind of strong political message to the government (as some ‘conspiracy analysts’ have suggested was at the root of all of Friday’s protests across the region). It seems to have been more simply an expression of anger at the Youtube film – with the US selected as the focal point for discharging that anger.

It might indeed be argued that there is every right and reason for such emotion – given both the mucky, unhinged nature of the film, and the central, deeply-ingrained part that its subject plays here. The means for expressing such feeling however, is another point entirely.

And the reasons for targeting the German embassy? It was reported in a Khartoum paper that an offensive cartoon was published in a German newspaper in the past 2 weeks. Elsewhere, one international media group suggested it was because the German government had not banned a right-wing protest at which anti-Islamic banners were held. And the UK embassy? No-one really seems to know specifically, perhaps just because it was next door? Perhaps because everyone knows it’s an old devil?!

As I left the faculty cafe that evening, and walked to the bus-stop, past restaurants and street-stalls, parked cars and open lorry-cabs, everywhere the same radio station was blasting out some kind of feverish exhortation. What was it? Reaction to the demonstrations? Demands for more protests?

No, it was football commentary.

Al-Hilal, one of the two big Khartoumi clubs was hosting Interclube Luanda from Angola in the African continental Confederations Cup.  If they won, they would be just one victory away from the semi-finals. We had been hoping to go this match (I was even wearing my Al-Hilal shirt), but decided that perhaps today was not the best day to be part of a large excitable crowd.

Whilst walking past people on the street, and waiting at the bus stop, I must admit to feeling a little bit nervous after the furore earlier. But the only bared teeth were set in smiles, and the several shouts aimed at me were all directed in praise of my Al-Hilal shirt.

So what should I conclude after all of that?

Were the demonstrations in Khartoum trivial? No.

Were they exaggerated in the desire to create a story of arching Middle-Eastern chaos? Yes, I think so.

Photo: CAF Online

Khartoumi society (still less Sudanese or Islamic culture) is not some monolithic conformity; 5,000 people from a city of 10 million is not such a large proportion (1 in every 2000 actually), whilst I need to take my shoes and socks off to count the number of people from my small circle of acquaintance here who have quietly apologised to me for the offense of the violent excesses. Overall, passions may be strong here, but are they really so different to those you might find in London or Barcelona, Madrid, Munich or Milan? There are people who like to burn things everywhere, but the majority have rather healthier interests, like the beautiful game. My decision that morning to wear an Al-Hilal shirt may have been inadvertently fortunate, but I don’t for a second believe that it saved my life.

—-

P.S. – From afternoon reports on Sunday 16th September

I’ve also seen reports in the international media that the Sudanese Foreign Ministry has refused to allow the US to deploy extra marines to protect its embassy – instead committing to use its own security forces. To my eyes, this story was put across with a negative, almost sinister spin, as if the buried question was “does the Sudanese government not want the US to be able to protect itself? Do they in fact want the US embassy to be imperiled?”

But isn’t it natural that a sovereign government should wish to trust its own security arrangements, and resent or refuse attempts to usurp its authority within its own capital city? Aren’t Sudanese forces likely to be more experienced and adept at handling Sudanese protesters than American marines? And couldn’t you argue that the government’s trust in its own forces was vindicated (at least as far as the US embassy goes)?

Heat Dreams

My room is its own little menagerie.
Above the bed, flocks of honking mosquitos flap about with their sharp bills and beady eyes. But they cannot find a way through my mosquito net to lay their golden eggs.

Below, cockroaches gambol merrily over the floor, stopping every now and then to pass the time of day. They whisper very quietly.

One afternoon we were even joined by an extremely handsome toad, about the size of a melon, with very fine mustachios and collars around his face. After we had processed three times around the room with gathering speed, he plopped gracefully into the little puddle which runs the length of one wall, and followed it out and under the door, which I closed behind him.

In the hallway outside, some kind of dragon-sized hornets have been making their mud-nests on the walls, and have stopped in for a drink and a snack in my room.

Across the road, there are goats who play ‘Here we go round the mulberry bush’ whenever I go past.

I think there should be some kind of story about what they all get up to, but I haven’t had that dream yet…

 

 

 

 

 

 

 

 

 

 

 All images from http://www.history.navy.mil/library/online/thisisann.htm

Leishmaniasis galore!

My placement at Soba Hospital hasn’t really settled into any kind of rhythm as yet. Its all a little bit haphazard. I’ve spent quite a number of hours just waiting around, wondering if I’m in the right place. In some ways thats reassuringly familiar – its a major educational dimension of just about every placement I’ve had in London too ! But its also rather familiarly frustrating.

So I’ve started taking a little more initiative, and have been creeping (walking) around the hospital, lurking (waiting) in the places where I know my team of doctors might be – the outpatients referral clinic, the male medical wards, procedure rooms and so on – and then jumping out (standing up) and asking if I can join them.

Through this subtle method, I’ve found out the times and specialties of the clinics each morning, and I’ve seen some very interesting patients.

For example I caught the last three patients in the chest clinic today. The first man had pulmonary TB (in the lungs), with bilateral pleural effusions (water in the lungs). The second was a young man with congestive cardiac failure (a bad heart), with a very clear textbook pansystolic murmur (his heartbeat sounded wrong).The final patient was a young lady in her 70s, who had disseminated TB, including pulmonary, lymphadenitis (Scrofula or TB in the lymph nodes of the neck), Pott’s Disease (TB in the spine) and a TB psoas abscess (an abscess in one of the muscles of the leg). All of this can (and would) be treated, although I’m not sure of the prognosis. (Photo of TB Lymphadenitis below taken with permission of patient)

On Mondays and Thursdays I go the Omdurman Hospital for Tropical Diseases, a 20 minute bus journey across the Nile from Khartoum.

Again, each morning starts gently with some stretching and yawning in the consultation room for an hour or so. But when the consultant arrives, its a fantastic learning experience. I think I probably saw more tropical medicine in my first clinic there, than most UK physicians get to see in their whole careers, and after each patient we discuss the case with the doctor.

From a 17 year old boy, with portal hypertension (high blood pressure in the liver’s blood vessels) from chronic schistosomiasis, through patients with TB, malaria, leprosy, suspected HIV, tertiary syphilis, others with schistosomiasis, to three patients with Cutaneous Leishmaniasis. This disease is endemic in parts of Sudan (as is Visceral Leishmaniasis). One of these patients has a typical history. He is a soldier in his 40s, in the Sudanese army, and has been stationed in the south of Sudan (in South Kordofan State). He has three circular, raised, painless lesions on his arm, the largest is around 5×6 cm, with a dry, ulcerated centre. These are caused by the body’s reaction to infection with a species of Leishmania parasite, which is transmitted via the bites of sandflies. If left untreated, they may resolve themselves, but (depending on the species) may also spread further, or cause Mucocutaneous Leishmaniasis (involving the linings of the nose and mouth) (which is worth avoiding). I think there is a multinationally-sponsored programme for Leishmaniasis in Sudan, and so he will be put into this and recieve for free the treatment of Sodium Stibogluconate (Pentostam). Whilst it may be good in the long run, it has to be administered via painful injections (the drug has local toxic effects) – so this man has some tough days ahead.

For me, tomorrow holds a gastroenterology clinc, so lets see what that throws up (sorry for the pun!).

Pete

Mix-ups and Marriages

Greetings from Khartoum!

Its Friday, the first day of the weekend here. And no,  I didn’t get married through some slight misunderstanding, but I have now completed my first working week (Sunday to Thursday) at Soba University Hospital, just outside Khartoum.

Its been great fun, but really all about finding my feet and getting my bearings. I’ve felt a little like a fish probably feels out of water – hooked by something I don’t quite understand, but realising that some pretty speedy evolution is going to be rather handy!

For example on my first proper day (after some introduction and orientation on the Sunday), I got to the front of my accommodation (I am staying in the doctors’ mess) to catch the shuttle bus to the hospital, which supposedly went at 08:00am. After waiting peacefully alone for a few minutes,  I went up to a man sitting in the shade of a tree nearby (the mess sits in a large scrub field a little way from Soba Hospital) to ask about the bus.

Me: Hi, is there a shuttle bus now?

Man: No bus.

Me: When is the next bus?

Man: Uh?

Me: (In faltering arabic) At what hour is the next bus that goes to the hospital of Soba?

Man: (In English) The next bus?

Me: Yes

Man: Not now.

Me: Oh (pause). At what time?

Man: Uh?

Me: (Arabic) At what time is the next bus?

Man: (English) This evening.

Me: Ah (pause). Okay, so I can walk?

Man: No.

Me: Oh (pause). But I think maybe I walked yesterday with one of the doctors?

Man: Not now, too hot.

Me: Ah (pause).

(We watch for a few seconds as some of the doctors from the mess stroll past on their walk in to the hospital)

Me: But I think really I should go in to the hospital, so maybe I should try to walk.

Man: Okay, I will walk with you.

From one perspective, I think this gives an idea of my first few days. Its taken just a little time to adjust to h0w things are – from routes into Soba Hospital and bus routes into Khartoum, to meal times, ways to stay hydrated, and how to shift my sleeping patterns to make the most of the cooler parts of the day (day time average is about 40 degrees C at the moment).

What that 2 minute ‘conversation’ barely touches though is just how friendly, welcoming and helpful so many people have been to me in these first few days – particularly at Soba Hospital and in the doctors’ mess. I spend my day shifts with the house officers, who mostly speak excellent English. They have helped me to see patients, taking some histories and doing examinations, correcting my clinical technique and encouraging me to try and pick up the odd medical word in arabic (and if I ever remember any they could be useful as many patients don’t really speak English).

I have also been to a pre-wedding ‘henna’ party – at the kind invitation of the chief administator at Soba Hospital – which I think is essentially about the groom (or the bride) celebrating the end of their single days and forthcoming marriage. From 21:00 onwards, around 200 people were up dancing to the live music and songs. One of the female singers in particular had a fantastic voice, kind of the female equivalent of Tom Waits, only I think with an even bigger set of lungs.

I have to come into Khartoum to use the internet (which takes around 40 mins via 2 microbuses) – so it may be less easy to blog as often as I had hoped.

I will post again soon – particularly about the medicine I’ve seen, including my first day at Omdurman Hospital of Tropical Medicine – where I will be spending 2 days a week from now on.

Pete