So the plan was to do a weekly clinic in the prison......
Week one:
Brendon, Nestor (our driver) and I are ushered into the heart of the prison with alomost no fuss. We were able to set up in a small room in the medical block. I had a desk to consult from. Bren and Nestor had another table from which to dispense all our medcines. Steven was allowed to come and help us and he brought one of his friends who was able to help me with translation.
We saw 25 or so patients in the morning, msotly things we could treat; musculoskeletal problems, high blood pressure; fungal infections; stomach ulcers.
A few patients had worrysome symptoms that would require investigation outside of the prison. There is a system for this and I was assured it would be arranged. The prisoners assisting witht he clinic seemed less confident.
One patient had epilepsy (I was later told there are 5 men in the prison with epilepsy) The prison pharmacy has no anti-epileptic medication and nor did I.
One patient had a hernia in the scar of a previous operation. He told me he had had appendicitis. His scar however was huge and implied that he hadn't been treated untill his appendix had burst, causing a more serous problem.
One patient told me he had a type of inherited heart problem. He did indeed have an enlarged heart. I wasn't however granted access to the medical files of these patients to see what tests they had had previously.
The prison doctors (4) were very friendly. They were welcoming and seemed keen to work together, though not offering me their files which did limit what I could do.
Treating prisoners was a first for me. Part of me was interested in what crimes they had commited. On reflection I'm glad I didn't know. Not only because I would have been more scared had I known, but more that I wasn't distracted from treating these men with the respect I would try to give every patient. In the respect and value which I tried to show, I hope to have communicated something to these men who live in very hard circumstances.
I left optamistic that I was being welcomed to be a part of a medical team working in a difficult environment with limited resources. I felt I had something to contribute; in bringing some extra medicines; in running some extra clinics and on working on the best treatment plans for patients with chronic illnesses.
Week two: no-one seemed interested in letting me in to do anything. None of the doctors made it out to meet me. I spent the morning in the waiting room.
I went home disappointed; and prayed a bit more, remembering that this had seemed to be the important aspect in the beginning.
Week three: The prison governor met me to ask if I would do the clinic for the guards. I was aware that this man holds all the power in the prison, so I was keen to play ball.
The prison serves 2200 inmates and employs 500 guards. They run regular health clinics for the staff as well.
One of them seemed rather unwell, a man in his 30's having been told previously that he had diabetes, but that day seemed to me to have some sort of liver problem. He was hopefully transferred to hospital. I've not had opportunity to see what kind of care is available in the hospitals here. i can only hope he gets the treatment he needs.
This time I went home happy to have done some medicine, telling myself that even if it wasn't group I had wanted to treat, they were still sick people and that is what I'm there for.
Week four: I'm told this time by the governor that I can no longer enter the prison untill I have a letter of authority from the govenment minister who overseas the prison service. It seemed pointless to try to argue that this seemed a strange thing to bring up now, and it been required of other people I had met who also do volunteer work within the prison.
Fortunately Sandra's husband had worked previously in that government department. He may be able to get my paperwork processed more quickly.
So we shall see. Its frustrating. I'm not the first person to comment that nicaraguan infrastructure seems designed to slow or obstruct progress. I still hope that there is more good to come of this.
Sunday, February 8, 2009
Monday, February 2, 2009
2 viewpoints on running a pharmacy
A little context:
The clinics I'm working in are funded by an english charity and a charge for each consultation. They are run by the charity "SIFT" on behalf of the local health authority. As such they are not duplicating other work and are a recognised part of the district's health service
The system seems to work. The two dollar charge is affordable to the majority of the community. The team know which of the patients are unable to pay and can waive the charge. The medicines are all dispensed free of charge.
The clinics funded by the health authority are, by comparison, completely free. They are well resourced with personnel but not with medicines. Many patients therefore have to pay high prices at local pharmacies for the medicines they need.
SO we have a better supply of medicines and cheaper overall for most patients. However there are still a lot commonly used medicines that we do not have, or have so little of that we could only treat a couple of patients for a month or two - not helpful for something like high blood pressure where treatment needs to continue for years. Its a horrible feeling as a doctor to make a diagnosis and not to be able to offer any treatment. We go throught this with cancers that cannot be treated or viruses that need not be treated. It is even harder to make a diagnosis, know that there is a good treatment but not have it available. This is a daily expereince here.
The Joys of being a pharmacist:
Each friday and saturday Dr sandra has a series of representatives from the pharmaceutical agencies visiting her. I like to think of these gentleman as her drug dealers. They have lists of which medicines they have available and what price. Sandra orders what she needs at the lowest prices as they become available, praying the different dealers off against each other.
And then there is the market in town. I like to think of this as the sweetie store. Its in the centre of the capital city's main market. It had to describe if you haven't seen large developing world market. Its one continuous construct of tin shacks built ajoining each other. Covering a couple of square kilometres, one can find absolutely everything. It is the centre of trade for most people in managua. Somewhere in this shopping jungle is a lady with a shack full of medicines. The market is a dangerous place and I was only allowed to some with sandra on the grounds that I brought no money, no valuables, no bag, and said as little as possible as the prices start to go up the more western and rich one looks. So I tagged along a couple of weeks ago.
Imagine being 8yrs old and being taken to a big sweetie store in town. Floor to ceiling with your favourite sweets that you have not seen in any of the corner shops and had almost forgotten what they tasted like. That was what I was feeling as looked round this medicine shack
I never thouhgt I would feel such affection for certain classes of medication. I guess it comes from having to give people a partially effective treatment, or one with many side effects, for want of having the "correct" treatments.
So we bought ourselves a nice little selection of our favourite medicines. I had a selection with which to run a half decent clinic in a certain prison you may have read about - if they would let me in; but that is a seperate story...
The Sadness of being a pharmacist.
The other side of procuring one's own medicines came a few days later.
On the island of ometepe, and in nicaragua generally, there is little in the way of refuse collection. A lot of household waste is therefore burnt instead.
I usually like fires, fascinating to watch and all that. This little fire was different. We'd been sorting through one of the clinic pharmacies, putting medicines in their correct places and checking their use by dates. The fire was made of the medicines we could no longer use because they were out of date. I'm sure every pharmacy in the owrld has to discard out of date medicines but I'd never done it before. It felt a little like burning books - simply wrong.
For those of you asking "why the wastage?", some will be unavoidable; one can never know exactly how much of any particular medicine is going to be needed in any given ammount of time. Some is because western aid agencies think it is useful to give large ammounts of medicines which have a few months to run on their use by dates to the third world. What seems a generous gift will inevitably be a large bonfire. Thirdly a more rigourous inventory of medicines including their use by dates may ensure they are dispensed in a systematic manner; ie those nearest their use by dates dispensed first. This may be a sizable task however.
The clinics I'm working in are funded by an english charity and a charge for each consultation. They are run by the charity "SIFT" on behalf of the local health authority. As such they are not duplicating other work and are a recognised part of the district's health service
The system seems to work. The two dollar charge is affordable to the majority of the community. The team know which of the patients are unable to pay and can waive the charge. The medicines are all dispensed free of charge.
The clinics funded by the health authority are, by comparison, completely free. They are well resourced with personnel but not with medicines. Many patients therefore have to pay high prices at local pharmacies for the medicines they need.
SO we have a better supply of medicines and cheaper overall for most patients. However there are still a lot commonly used medicines that we do not have, or have so little of that we could only treat a couple of patients for a month or two - not helpful for something like high blood pressure where treatment needs to continue for years. Its a horrible feeling as a doctor to make a diagnosis and not to be able to offer any treatment. We go throught this with cancers that cannot be treated or viruses that need not be treated. It is even harder to make a diagnosis, know that there is a good treatment but not have it available. This is a daily expereince here.
The Joys of being a pharmacist:
Each friday and saturday Dr sandra has a series of representatives from the pharmaceutical agencies visiting her. I like to think of these gentleman as her drug dealers. They have lists of which medicines they have available and what price. Sandra orders what she needs at the lowest prices as they become available, praying the different dealers off against each other.
And then there is the market in town. I like to think of this as the sweetie store. Its in the centre of the capital city's main market. It had to describe if you haven't seen large developing world market. Its one continuous construct of tin shacks built ajoining each other. Covering a couple of square kilometres, one can find absolutely everything. It is the centre of trade for most people in managua. Somewhere in this shopping jungle is a lady with a shack full of medicines. The market is a dangerous place and I was only allowed to some with sandra on the grounds that I brought no money, no valuables, no bag, and said as little as possible as the prices start to go up the more western and rich one looks. So I tagged along a couple of weeks ago.
Imagine being 8yrs old and being taken to a big sweetie store in town. Floor to ceiling with your favourite sweets that you have not seen in any of the corner shops and had almost forgotten what they tasted like. That was what I was feeling as looked round this medicine shack
I never thouhgt I would feel such affection for certain classes of medication. I guess it comes from having to give people a partially effective treatment, or one with many side effects, for want of having the "correct" treatments.
So we bought ourselves a nice little selection of our favourite medicines. I had a selection with which to run a half decent clinic in a certain prison you may have read about - if they would let me in; but that is a seperate story...
The Sadness of being a pharmacist.
The other side of procuring one's own medicines came a few days later.
On the island of ometepe, and in nicaragua generally, there is little in the way of refuse collection. A lot of household waste is therefore burnt instead.
I usually like fires, fascinating to watch and all that. This little fire was different. We'd been sorting through one of the clinic pharmacies, putting medicines in their correct places and checking their use by dates. The fire was made of the medicines we could no longer use because they were out of date. I'm sure every pharmacy in the owrld has to discard out of date medicines but I'd never done it before. It felt a little like burning books - simply wrong.
For those of you asking "why the wastage?", some will be unavoidable; one can never know exactly how much of any particular medicine is going to be needed in any given ammount of time. Some is because western aid agencies think it is useful to give large ammounts of medicines which have a few months to run on their use by dates to the third world. What seems a generous gift will inevitably be a large bonfire. Thirdly a more rigourous inventory of medicines including their use by dates may ensure they are dispensed in a systematic manner; ie those nearest their use by dates dispensed first. This may be a sizable task however.
Thursday, January 8, 2009
one for the doctors reading
An 8 yr old boy with an arthritis affecting both elbows and his left ankle. Marked pain swelling and restirction of movement.
symptoms and inflammatory markers settling after a course of herbal medicine and anti-inflamatories.
Bloods: 6/9/08:
CRP: 384 mg/L
ESR: 55
Rheumatoid factor: Positive
30/11/08
CRP: "negative"
ESR: 40
Rheumatoid factor: Negative
WCC: 8.9
I'm not sure how reliable the labs are nor what a constitutes a negative CRP?!
On examination he has marked swelling of a his right elbow and right ankle, only a little warm to the touch and moderately painful on all movements. Just about a ful range of movement at both.
Also He has an ejection systolic murmor radiating to his carotids, with no signs of symptoms of heart failure.
What is the next step: all ideas welcome............... further questions............?
symptoms and inflammatory markers settling after a course of herbal medicine and anti-inflamatories.
Bloods: 6/9/08:
CRP: 384 mg/L
ESR: 55
Rheumatoid factor: Positive
30/11/08
CRP: "negative"
ESR: 40
Rheumatoid factor: Negative
WCC: 8.9
I'm not sure how reliable the labs are nor what a constitutes a negative CRP?!
On examination he has marked swelling of a his right elbow and right ankle, only a little warm to the touch and moderately painful on all movements. Just about a ful range of movement at both.
Also He has an ejection systolic murmor radiating to his carotids, with no signs of symptoms of heart failure.
What is the next step: all ideas welcome............... further questions............?
La concepcion
is a volcano on the northern part of ometepe, and stands at 1610m tall. Fot the walking geeks amongst you that is 266m higher than be nevis.
Its a long climb. we started 2hrs late having found our guide laid out asleep in the bus shelter distinctly hung over. He called himself a guide, and to be fair he did know the way. However he struggle to keep up, was laid down and trying to sleep every time we stopped, and hadn't brought any food or water with him.
So we fed him and watered him and got him to the top, muttering and grumbling and looking more than a little sorry for himself. I don't think a canter up a mountain made for a good hangover cure.
The top was an incredible change of climate. Enshrouded in a near permanent cloud, we were drenched with what felt like a sharp sleet-like rain, driven by gale force winds up towards the crater. This while it was a still sunny day down at sea level.
The crater's edge was covered in warm ash, and the air was sulphorous and difficult to breathe - not a pleasant place.
There were some good views though
Friday, January 2, 2009
Who believes that prayer works?
On the 30th december, brendan and I (with many people at home in the UK) spent the day praying for, and visiting stephen. A man who lives a couple of roads up from us in quinton but happens to be in prison here in nicaragua.
While praying that day, I felt that It may be really good to do some medical work in the prison. We had heard from stephen that healthcare there was not all it could be.
This thought kept nagging at me through the day.
We asked friends working here, and those who have visited the prison previously what they thought. We were told that the prison is incredibly beaurocratic and it can take a very long time to get anything organised. We had also seen for ourselves how unhelpful the staff can be, and had heard that the prison governor, whose permission I would need, can be particularly unhelpful.
We prayed some more and still considered it an idea worth pursuing, so the next day we went back with the prison armed with a letter explaining my ideas in my rather sketchy spanish.
I was met at the gate by the guards who called the prison doctor. He came straight away and seemed very pleased to meet me. He introduced me to the prison governor and we had lunch together (quite a tasty chicked dish with iced tea!). After lunch I explained (again in my most "fluent" spanish) my idea: I would be working three and a half days a week in ometepe, so would be free on fridays and could come and do a joint clinic with the doctor in the prison.
They semed very happy to accept this offer and all was agreed. The only problem being that they have few medicines in the prison, and not many of the prisoners can afford to buy them from outside.
There was minimal paperwork to be completed, and I was only in the prison for 40 minutes.
I have not heard of anything happen so quickly within the nicaraguan public sector, and I was amazed at the prompt and welcoming response of the governor.
It is to me too much of a coincidence that we spend that time praying and then this opportunity opens up in such a way.
We believe we are seeing the influence of God.
As such i am very excited about this opportunty - lets pray again and see what happens next!
While praying that day, I felt that It may be really good to do some medical work in the prison. We had heard from stephen that healthcare there was not all it could be.
This thought kept nagging at me through the day.
We asked friends working here, and those who have visited the prison previously what they thought. We were told that the prison is incredibly beaurocratic and it can take a very long time to get anything organised. We had also seen for ourselves how unhelpful the staff can be, and had heard that the prison governor, whose permission I would need, can be particularly unhelpful.
We prayed some more and still considered it an idea worth pursuing, so the next day we went back with the prison armed with a letter explaining my ideas in my rather sketchy spanish.
I was met at the gate by the guards who called the prison doctor. He came straight away and seemed very pleased to meet me. He introduced me to the prison governor and we had lunch together (quite a tasty chicked dish with iced tea!). After lunch I explained (again in my most "fluent" spanish) my idea: I would be working three and a half days a week in ometepe, so would be free on fridays and could come and do a joint clinic with the doctor in the prison.
They semed very happy to accept this offer and all was agreed. The only problem being that they have few medicines in the prison, and not many of the prisoners can afford to buy them from outside.
There was minimal paperwork to be completed, and I was only in the prison for 40 minutes.
I have not heard of anything happen so quickly within the nicaraguan public sector, and I was amazed at the prompt and welcoming response of the governor.
It is to me too much of a coincidence that we spend that time praying and then this opportunity opens up in such a way.
We believe we are seeing the influence of God.
As such i am very excited about this opportunty - lets pray again and see what happens next!
Tuesday, December 30, 2008
Stephen 2
So we saw stephen today in prison.
Thank-you to all of you who remembered us and him in your prayers.
He was in good spirits, seemed in good health, and was very happy to see us.
The most noticable effect from 5yrs in prison here is that he mixes a lot of spanish words into his english.
He told us how he shares his cell with 5 others. Fortunately they get along well and look out for each other. Food is the standard local guyo pinto (rice and peas) but of a pretty poor quality and not hygienically prepared. He is able to cook his own food as and when he has the means to buy ingredients.
Medicines (even stiches) he has had to pay for if he is able. He remembers a time after sustaining an injury to his arm when he was not able to get even paracetamol.
There is not a lot to do. Work is a privelege for a few because it earns money and there is not enough work for everyone.
He seems to be managing very well in a hard hard place.
Next week brendan hopes to return with some books and a bit more food.
Thank-you to all of you who remembered us and him in your prayers.
He was in good spirits, seemed in good health, and was very happy to see us.
The most noticable effect from 5yrs in prison here is that he mixes a lot of spanish words into his english.
He told us how he shares his cell with 5 others. Fortunately they get along well and look out for each other. Food is the standard local guyo pinto (rice and peas) but of a pretty poor quality and not hygienically prepared. He is able to cook his own food as and when he has the means to buy ingredients.
Medicines (even stiches) he has had to pay for if he is able. He remembers a time after sustaining an injury to his arm when he was not able to get even paracetamol.
There is not a lot to do. Work is a privelege for a few because it earns money and there is not enough work for everyone.
He seems to be managing very well in a hard hard place.
Next week brendan hopes to return with some books and a bit more food.
San Juan del sur
We had a couple of days on the pacific coast - San juan del sur, in the far south west of the country.
Staying in a mosquito infested hovel (because it was cheap) and spending our days, reading, swimming and relaxing.
oh and watching the sun go down...........
ok so that is the yealm estuary but who was to know?
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