November 19, 2007
Some have critiqued HIV treatment programs for being narrowly designed – even directing a disproportionate amount of “limited resources” towards one disease at the expense of others. As Paul Farmer has argued (see Foreign Affairs), this is only the case if treatment programs are not designed effectively.
With the aim of promoting equity, Tiyatien Health seeks to leverage “marvelous momentum” for AIDS care to strengthen primary healthcare in general. We have found that even modest interventions can help result in healthcare for all. For instance, all of Tiyatien’s accompaniers are asked to bear responsibility for tending to any sick individual in the communities where their AIDS patients live. Following this principle, 17 accompaniers found nearly 150 sick individuals in communities around Zwedru, during home visits to AIDS patients. All were referred to clinic and some of these people were found to have and treated for life-threatening illnesses like tuberculosis, severe anemia and malaria. Some may have otherwise have had delays in diagnoses, possibly leading to death.
In addition to visiting three AIDS patients on Sunday morning, Dweh and I were able to facilitate uptake of primary healthcare for four other sick individuals with a range of conditions including quadriplegia, respiratory infections and malaria. We also found “Papa Joseph”, a man with liver failure, who had been unable to attend a follow-up visit (due to cost of transportation to the hospital) after being discharged from the hospital last month. He was in a critical condition. His failed liver had led fluid to slowly reaccumulate in his abdomen – causing it to distend as tense as a soccer ball. We found him in his home, lying on a mat on a dirt floor, unresponsive. We called for an ambulance and he is now at Tubman hospital receiving acute management.
Home visits with our accompaniers remind of the importance of Tiyatien’s work in rural Liberia, where AIDS isn’t the only disease afflicting the poor.
Some have asked whether Tiyatien’s accompaniers get tired as some walk for long distances on a daily basis to reach their patients’ homes. When I think of accompaniers and their patients, I am reminded of Mahatma Gandhi’s wisdom, who after leading long marches to promote freedom and justice during India’s revolution, said: “My feet may be tired, but my soul is rested.”
Tiyatien’s accompaniers are carrying on the march towards justice in Liberia.
Wednesday, November 21, 2007
Reflections on Home Visits with Accompaniers
November 18, 2007
Accompaniers form the backbone of Tiyatien Health and the HIV Equity Initiative here in Zwedru. Accompaniers, selected by neighbors or loved ones with HIV, are trained by Tiyatien and MoH staff to provide “accompaniment” to AIDS patients and their families through: daily delivery of life-saving antiretroviral medications; moral and psychosocial support; delivery of food packages; direct links to the health center in cases of illness, side effects or toxicity; education on HIV/AIDS. They also serve as a link for any sick individuals living in communities they serve.
This morning, I joined one of Tiyatien’s accompaniers, Plugbe Dweh, on his daily home visits to deliver life-saving antiretroviral medicines to AIDS patients. Most care for the destitute sick, of course, occurs in the home rather than the hospital. So, home visits are enlightening. They teach about patients, their families, their life histories, their hardships, as well as their hopes. Dweh and my visits this morning were no different.
Home visits to Nancy, Susy and Victoria
I left my hospital-based lodge at daybreak and met Dweh at 7:00am in the center of town. By 7:15am, we reached Nancy’s home. She lives in a white, tin-roofed hut with walls embedded by multiple bullet holes – stark reminders that Liberia’s brutal civil wars were all too recent. Dweh called for Nancy’s mother, who escorted us through the brown curtain overlaying the entrance to Nancy’s room. The sunlight piercing through the room’s single window hardly brightened the dark, murky interior.
Lying in her bed, Nancy stared up at us with a smile. She is a frail young woman, only a few inches above 5 feet in height and weighing only 60lbs. Her thin, tan-colored skin drapes tightly around the contour of her ribs and clavicles. She did appear a bit stronger than when I admitted her to Tubman Hospital, six weeks earlier, for severe anemia and a fungal infection in her mouth. Now, she was barely able to rise out of her bed on her own.
Nancy’s life has been plagued by tragedy. Born in Liberia’s capital, Monrovia, Nancy was displaced with her family into camps at the start of Liberia’s civil war in 1990. Although theirs was a large family – Nancy was one of eight children – a vicious cycle of disease, violence and poverty had claimed the lives of many loved ones. Her father was ill when war first hit. With fighting in the streets abound, food quickly became scarce. In the middle of it all, Nancy’s mother said, her husband starved to death.
Illness and war had other terrible effects. Four of Nancy’s seven siblings had died. Measles and diarrhea had killed two of them in infancy. One died at the age of eight when shrapnel from a rocket became embedded in his abdomen. The other died soon after a complicated birth.
As AIDS began to claim Nancy’s life, her mother made the decision to move to Zwedru, home of Tubman Hospital, which provided services free-of-charge thanks to support from the Ministry of Health and Merlin, a British relief agency. She is relieved that the correct diagnosis has finally been made. And treatment is providing hope, with Dweh standing by her in solidarity. He delivered her HIV medications to her during our visit, as he does everyday. This week he also delivered a food package filled with oil, corn soya-blend, bulghar wheat, and salt. We scheduled an appointment for her in two days and left with her some money to pay for transportation to attend clinic.
We left Nancy’s place at nearly 8:30am and walked about four miles to see two more of Dweh’s patients. We stopped to deliver medicines to Susy at 8:53am and to Victoria at 9:20am. Fortunately, having been on antiretroviral medicines and cared for by Dweh for many weeks, they were now both relatively well.
Dweh’s solidarity with his patients can only serve to inspire. He and his fellow accompaniers are providing life-saving care here in southeastern Liberia, the country’s poorest region.
Accompaniers are on the frontlines of a movement that seeks to prove high-quality care for complex diseases can be delivered even in the world’s most impoverished regions.
Accompaniers form the backbone of Tiyatien Health and the HIV Equity Initiative here in Zwedru. Accompaniers, selected by neighbors or loved ones with HIV, are trained by Tiyatien and MoH staff to provide “accompaniment” to AIDS patients and their families through: daily delivery of life-saving antiretroviral medications; moral and psychosocial support; delivery of food packages; direct links to the health center in cases of illness, side effects or toxicity; education on HIV/AIDS. They also serve as a link for any sick individuals living in communities they serve.
This morning, I joined one of Tiyatien’s accompaniers, Plugbe Dweh, on his daily home visits to deliver life-saving antiretroviral medicines to AIDS patients. Most care for the destitute sick, of course, occurs in the home rather than the hospital. So, home visits are enlightening. They teach about patients, their families, their life histories, their hardships, as well as their hopes. Dweh and my visits this morning were no different.
Home visits to Nancy, Susy and Victoria
I left my hospital-based lodge at daybreak and met Dweh at 7:00am in the center of town. By 7:15am, we reached Nancy’s home. She lives in a white, tin-roofed hut with walls embedded by multiple bullet holes – stark reminders that Liberia’s brutal civil wars were all too recent. Dweh called for Nancy’s mother, who escorted us through the brown curtain overlaying the entrance to Nancy’s room. The sunlight piercing through the room’s single window hardly brightened the dark, murky interior.
Lying in her bed, Nancy stared up at us with a smile. She is a frail young woman, only a few inches above 5 feet in height and weighing only 60lbs. Her thin, tan-colored skin drapes tightly around the contour of her ribs and clavicles. She did appear a bit stronger than when I admitted her to Tubman Hospital, six weeks earlier, for severe anemia and a fungal infection in her mouth. Now, she was barely able to rise out of her bed on her own.
Nancy’s life has been plagued by tragedy. Born in Liberia’s capital, Monrovia, Nancy was displaced with her family into camps at the start of Liberia’s civil war in 1990. Although theirs was a large family – Nancy was one of eight children – a vicious cycle of disease, violence and poverty had claimed the lives of many loved ones. Her father was ill when war first hit. With fighting in the streets abound, food quickly became scarce. In the middle of it all, Nancy’s mother said, her husband starved to death.
Illness and war had other terrible effects. Four of Nancy’s seven siblings had died. Measles and diarrhea had killed two of them in infancy. One died at the age of eight when shrapnel from a rocket became embedded in his abdomen. The other died soon after a complicated birth.
As AIDS began to claim Nancy’s life, her mother made the decision to move to Zwedru, home of Tubman Hospital, which provided services free-of-charge thanks to support from the Ministry of Health and Merlin, a British relief agency. She is relieved that the correct diagnosis has finally been made. And treatment is providing hope, with Dweh standing by her in solidarity. He delivered her HIV medications to her during our visit, as he does everyday. This week he also delivered a food package filled with oil, corn soya-blend, bulghar wheat, and salt. We scheduled an appointment for her in two days and left with her some money to pay for transportation to attend clinic.
We left Nancy’s place at nearly 8:30am and walked about four miles to see two more of Dweh’s patients. We stopped to deliver medicines to Susy at 8:53am and to Victoria at 9:20am. Fortunately, having been on antiretroviral medicines and cared for by Dweh for many weeks, they were now both relatively well.
Dweh’s solidarity with his patients can only serve to inspire. He and his fellow accompaniers are providing life-saving care here in southeastern Liberia, the country’s poorest region.
Accompaniers are on the frontlines of a movement that seeks to prove high-quality care for complex diseases can be delivered even in the world’s most impoverished regions.
Monday, November 5, 2007
Seeking Hidden Accounts of Atrocity
From the New York Times, a piece on Liberia's Truth and Reconciliation process in the United States:
Matt
After three years spent collecting narratives from survivors of Liberia's civil wars, Ms. Kamara-Umunna has instincts. She believed she had spotted a former child soldier, vanished almost seamlessly into a community 4,500 miles from home. If she had antennas, they would have trembled.http://www.nytimes.com/2007/10/31/nyregion/31reconcile.html
Ms. Kamara-Umunna, too, blends easily into this neighborhood, among thousands of Liberian refugees in northeast Staten Island. But she has come to New York on a mission.
In Liberia, she specializes in persuading former child soldiers — men with every reason to keep silent — to give oral histories, sometimes confessing acts of bewildering violence on her radio program there.
Matt
Friday, November 2, 2007
PLoS ART Retention Article
PLoS Medicine recently published a review of patient retention in ART programs in sub-Saharan Africa, which some of you may find interesting. The review looked at 33 patient cohorts in sub-Saharan Africa to determine retention after ART enrollment. It found mean 6-month retention of about 80%; mean 2-year retention of about 60%. Of this, mortality comprised 40% of the attrition and loss to follow-up comprised 56%. The best performance was 90% 2-year retention. Happily, the 6-month attrition in Zwedru is be better than the 80% mean.
The full text of the article can be found here.
John
The full text of the article can be found here.
John
Update from Zwedru
Hi all,
here with a rapid update. as you can tell there has been a flurry of activity over past month (October) on the HIV Equity Initiative.
Highlights are:
(1) HEI's First Report Complete -- Completed report on 6 months of implementation and submitted to Nat'l AIDS Control Program and Ministry of Health.
(2) HEI 2-year proposal submitted -- Submitted propoal for block grant from Global Fund (via Nat'l AIDS Control Program) to cover project activities over 2 years.
(3) HEI continues to care for more patients -- Of course, our clinical activities are ongoing and the HIV Equity Initiative has now enrolled over 70 HIV patients into treatment and care, with nearly 35 receiving ART. 20 are being followed by an accompanier. It's been such a joy to see the reclaiming of lives that would have been lost much too early. Patients whom have gained over 20kgs and re-started work after months to years of suffering. And all new patients (from Tchien) are now asked to send their neighbors for accompanier training each month. Next training is to be held on Nov 10-11. So our community-based HIV care approach is growing beyond Zwedru and into Tchien district.
(4) Formalizing our partnership with Ministry of Health -- Weafus (accompanier supervisor) and I met with Netus (the Chief Administrator for Grand Gedeh County Health services; equivalent to North Carolina Secretary of Health) and he is happy to formalize Tiyatien's partnership with them regarding the HIV Equity Initiative. So we'll develop a Memorandum of Understanding (MOU) and circulate for feedback next week.
(5) Laying groundwork for expanding community-based HIV and primary healthcare -- Finally, I also mentioned to Netus that we hope to expand HEI's work into a rural clinic (to prove that high-quality HIV care can be delivered even at this level). In so doing, we would hope to expand and re-establish primary care services writ large. Coincidentally, there was a young man representing a community called Tarloken (in Konobo district; 6 hours from Zwedru) that has requested support from the Ministry of Health for a clinic they've just rebuilt using makeshift materials. Will try to visit this and other potential clinic sites before returning in late November. Over the next several months, we could work to identify a clinic site into which HEI could be expanded. Once we've done this, we could build on the success of the HEI in Zwedru and push for funding to help the new site become accredited for delivering ART (which, according to Liberia's new guidelines, requires basic infrastructure -- maternal/child services, clinical staff, laboratory resources..etc). In this way, we would be leveraging HIV resources to help stregthen primary healthcare infrastructure.
yours from Zwedru,
Raj
here with a rapid update. as you can tell there has been a flurry of activity over past month (October) on the HIV Equity Initiative.
Highlights are:
(1) HEI's First Report Complete -- Completed report on 6 months of implementation and submitted to Nat'l AIDS Control Program and Ministry of Health.
(2) HEI 2-year proposal submitted -- Submitted propoal for block grant from Global Fund (via Nat'l AIDS Control Program) to cover project activities over 2 years.
(3) HEI continues to care for more patients -- Of course, our clinical activities are ongoing and the HIV Equity Initiative has now enrolled over 70 HIV patients into treatment and care, with nearly 35 receiving ART. 20 are being followed by an accompanier. It's been such a joy to see the reclaiming of lives that would have been lost much too early. Patients whom have gained over 20kgs and re-started work after months to years of suffering. And all new patients (from Tchien) are now asked to send their neighbors for accompanier training each month. Next training is to be held on Nov 10-11. So our community-based HIV care approach is growing beyond Zwedru and into Tchien district.
(4) Formalizing our partnership with Ministry of Health -- Weafus (accompanier supervisor) and I met with Netus (the Chief Administrator for Grand Gedeh County Health services; equivalent to North Carolina Secretary of Health) and he is happy to formalize Tiyatien's partnership with them regarding the HIV Equity Initiative. So we'll develop a Memorandum of Understanding (MOU) and circulate for feedback next week.
(5) Laying groundwork for expanding community-based HIV and primary healthcare -- Finally, I also mentioned to Netus that we hope to expand HEI's work into a rural clinic (to prove that high-quality HIV care can be delivered even at this level). In so doing, we would hope to expand and re-establish primary care services writ large. Coincidentally, there was a young man representing a community called Tarloken (in Konobo district; 6 hours from Zwedru) that has requested support from the Ministry of Health for a clinic they've just rebuilt using makeshift materials. Will try to visit this and other potential clinic sites before returning in late November. Over the next several months, we could work to identify a clinic site into which HEI could be expanded. Once we've done this, we could build on the success of the HEI in Zwedru and push for funding to help the new site become accredited for delivering ART (which, according to Liberia's new guidelines, requires basic infrastructure -- maternal/child services, clinical staff, laboratory resources..etc). In this way, we would be leveraging HIV resources to help stregthen primary healthcare infrastructure.
yours from Zwedru,
Raj
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