Dear Diary

Day 1 (er, 2…) – Tuesday

So I’m at Saint Francis now. Got here yesterday after saying my goodbyes to Chris, Amy and Kondwani (they were headed to Katondwe for a week and will leave for the US while I’m here) and hopping a bus for the torturous seven-hour ride to Katete. I’d have slept (I’d only gotten about two hours the night before) but I managed to find myself on the only bus you’re supposed to avoid when traveling to Katete and I was too busy hanging on for dear life.

Anyhoo, but I made it. And I’m not staying with Shelagh this time. This time, I’m like a real, honest-to-goodness volunteer (weee!), which means I’m staying in one of the short-term volunteer houses (got a roommate, even – an older Canadian mid-wifery teacher who’s here for a couple weeks with her students) and taking meals at the mess. The house is small and spare, but it’s got running water (although not hot), power (although not all the time), a stove (although it doesn’t turn off unless you unplug it and then sometimes it won’t turn back on) and even a fridge. We could cook, if we were so inclined, except that the closest grocery store is nearly two hours away. And there’s no shower, so we boil water (when there’s power, which there wasn’t tonight, which also meant there was no dinner) and “take a bucket”, crouching, in the tub. It’s a total pain in the ass, but I kinda friggin’ love it (although ask me again in three weeks how I feel…).

This morning, I attended the weekly Tuesday morning clinician’s meeting where I met Jeremiah, the head pharmacist (and my new best friend), and then spent the day in the dispensary; my sole aim was to begin building relationships with the guys and to start to understand the general workflow process. But they were short-staffed (no surprise there) so I got a crash course in pharmacy tech and was soon counting pills, fetching stock, and even dispensing scrips to patients (Tubili tubili katatu pa tsiku, if you’re interested, is Chinyanja for “Take two pills three times a day”). It wasn’t terribly complicated (although I have to say, I suck at doing math in my head), but it was terribly chaotic. Open pill bottles scattered randomly across the counter, half-filled prescriptions strewn about, pharmacy assistants running around, stock movement sheets sliding out of the three-ring binders where they're kept… So far, it seems, the only system in pharmacy is that there is no system. But given the number of patients to be seen and the number of pharmacy staff to see them, I’m just amazed that anyone walks away with a scrip filled at all.

From managing the stock to moving the stock to dispensing the stock, every single process is done manually – and only if there’s time – which generally means that, with the exception of the last part (dispensing to patients), it doesn’t get done at all (or at least not with any accuracy or timeliness). One could argue, I suppose, that they’re at least attending to the most important piece, and one would be right…sorta. Except that now there is an even bigger issue – drug shortages. When you don’t have time to manage your stock, you don’t always know how much you’re using or realize when it’s time to order more. And if you don’t order more, you can’t (duh) get more, which means – ultimately – neither can the patients. This is an especially critical matter when it comes to ARVs, which require strict adherence not only to work effectively but to reduce the chances that a patient will develop resistance. At Saint Francis, they’re having particular trouble managing their stock of Truvada, the drug that is the government-recommended first-line therapy for all HIV patients. They ran out of it a few months ago, so they stopped prescribing it, which meant that their reported consumption of it was artificially low and, since future drug orders are typically based on historical consumption, they haven’t been able to order as much of it as they really need so they keep falling deeper into the hole – all of which means that the folks who really need it, the patients, aren’t getting it.

Which is where this new software that I’m meant to implement comes in. Shelagh and Ian (her husband, who is also the hospital administrator) are hoping that if we can put something in place that will help to automate some of the processes, we might more effectively manage them. My plan, then, is to spend the rest of this week working alongside the guys and learning more about the way it all works so that I can evaluate whether or not mSupply is indeed the best solution and, if it is, begin developing the implementation plan for it and banging out the tasks.

Day 3 – Wednesday

Spent the day in pharmacy again. Met with Jeremiah briefly in the morning, and then the sh*t hit the fan and they were still short-staffed so I got to literally get my hands dirty again (I was covered, head to foot, in the bitter, powdery residue of the pills) helping to fill and dispense scrips. Then the truck came from medical stores (the government supplier) with the monthly delivery (although no Nevirapine, another important ARV; and still no Truvada). I helped unload and pack the storeroom and by the time we finished I was a complete mess. It was fantastic! My shoulders ache and my feet are killing me, but I finally feel like I’m doing something. Something tangible anyway, something I can see and measure.

I also met the hospital’s purchasing officer and learned about how they procure the drugs (and other medical supplies) that are not provided by the government or donor countries and how they receive and track those (manually, of course, in triplicate, in a carbon copy Goods Received notebook which frequently disappears, along with the invoices that are meant to be entered into it). mSupply, in addition to being a general stock management tool, also tracks supplier quotes, purchase orders and invoices, so this is another area where we could improve processes.

Oh, and I think I’ve solved the Truvada crisis for the hospital. Nothing particularly imaginative or creative – I just made a phone call. Called Robb (my brother’s boss at AIDSRelief) and asked him if he knew where we could get our hands on some. He said that AIDSRelief was sitting on so much that they were afraid it was going to expire and that he’d email Lameck (the procurement officer for AR) that night and authorize the immediate release of 1000 bottles (roughly a three-month supply) for SF. J Given the number of patients already on it and how many more are being enrolled in therapy every day, they will more than likely burn through this supply in little more than a month. But – the good news is that this increased consumption will be reflected in their reports, which means they’ll be able to order more, which means that (at least theoretically) they’ll get more and they’ll be back on track.

Day 4 – Thursday

Started today counting pills for pre-packs in the OPD (outpatient) dispensary, then got bumped to the ART dispensary working with Stanislas. He dispensed the ARVS and I recorded each scrip in the computer (in the spreadsheet I built for them when I was here last February – their interim solution until mSupply is up and running – but which apparently they haven’t been using. Sigh…). I dig Stanislaus, although I am a little worried about him. He’s kind of crotchety (totally atypical for a Zambian, as they are generally a really happy people) and he always smells vaguely of alcohol. And today I noticed a tremor in his leg when he was dispensing to a patient and saw him try to cover it. I don’t know – maybe it’s nothing. There’s just something about him that makes me sad, though, so it’s kind of my sole aim to make him laugh as much as I can every day.

We were slammed, though (again) and worked straight through lunch. I spent the day swinging wildly between feeling frustrated by the way things (don’t) get done here and being totally awed that they do at all. It never stops being overwhelming, the stuff these people have to deal with. And it’s always the sh*t you take for granted, too. Like having a reliable power or water supply; or a car to get you where you need to go; or, I don’t know, tech support. I mean, if your cell phone breaks you have to take an entire day off work so you can ride the nearly two hours to Chipata to get it fixed (or buy a new one). If your computer crashes or your internet goes down, it’s literally weeks before anyone can take a look at it. If the patient information system that the really nice Dutch (wait, is it Dutch?) volunteer built for you bugs out, well, you’re pretty much SOL – even if you really need the reports it’s meant to generate – because he’s back in Holland now and not exactly available to provide ongoing system maintenance and so you’ll just have to manually generate them now.

Not to mention what the patients themselves face. Most of them can’t speak, never mind read, English and yet they’re expected to strictly adhere to complicated treatment regimens with only written instructions in English to guide them. And then there are the meds that require refrigeration to keep from spoiling, except – oh wait – the average villager doesn’t even have electricity, never mind a fridge (the pharmacists don’t even bother telling them that they need to be refrigerated which initially pissed me off – until I realized how pointless telling them would be). Or how ‘bout something as simple as the mother who’s expected to split a tiny 5mg pill into quarters for her child. Do you think she owns a pill cutter? The pharmacy doesn’t even have a pill cutter. I almost cried when I was filling a scrip for this one kid and I realized that we didn’t have the dose the doc had prescribed. He was supposed to get 100mg but the caps only come in these tiny 200mg rounded tabs (in other words, not the flat, pre-scored tabs that are conducive to splitting). “How will this mother give her child his medicine?” I asked Stan.

“Ah, but I think the mother knows how to break in half,” he told me.

“Right. Of course,” I said, nodding. “Sooo…can you do it?” I asked, holding out the pill. I didn’t mean to be cheeky, and I know it was “just” ibuprofen and not, say, life-saving ARVs or anti-malarials, but it wasn’t the first time I’d seen a patient handed a scrip with a dose they were essentially going to have to figure out on their own and it was starting to frustrate me.

He took it from my hand and tried to break the rounded pill to no avail. “Ah, but she will just use a knife,” he said, then set it aside and went back to counting the pills for the fifty other scrips he was trying to fill at the same time.

“But…will she have a knife sharp enough to cut it without smashing it?” I persisted. He looked at me for a second then disappeared, then was back a minute later with a surgical blade he’d scavenged from the storeroom. “This’ll do,” I said, and then sliced every single one of those pills as close to in half as I could manage.

It’s maddening. And I imagine if Stan thought he had time to cut every single pill for every mother that needed him to he would; or that Temba would explain, to each patient that needed to know, how they might create a small refrigerator out of a clay pot, sand, and water. But there’s no time for that here. Or anywhere, for that matter. Every hospital I’ve visited since I’ve come here has been wildly understaffed and stretched almost to the breaking point, although Saint Francis is among the worst (if only for how huge it is – their catchment area is ginormous). I honestly don’t know how it’s still functioning – except that there really is always someone who puts forth some Herculean effort to get you over the hump, to get you through to the next day. Because, I mean, who wants to be the guy that tells the patient who was brought to the hospital in the middle of the night in the back of a pick-up truck, bleeding from the head, “Yeah, sorry. I’m just too tired – I’ve already been on call three nights this week” – even if you have? Who wants to tell the patient who just walked seven hours just to get their next three-month supply of meds, “Sorry, my friend. Pharmacy’s closed now – come back tomorrow” – even if you have been on the clock for almost ten hours already and you still have however many kilometers to walk back to your own house?

There’s a quote that I’ve read before, which has been attributed to a million different people, that I keep thinking about: “Do all you can with what you have in the time you have in the place that you are.”

That really is as much as you can hope for.

Day 5 – Friday

Ok, I’m pooped. Spent almost the entire day helping Thomas move and shelve the stock that we unloaded on Wednesday. Scarcely had time to break for lunch or even pee. I loved it, though. I feel like I’m finally, I don’t know, “earning my keep”; like I’m finally doing what I came to do. But I’m pooped.

Oh, and my roommate left today, so now I’ve got the house all to myself.

Day 6 – Saturday

So it was just Thomas and me in pharmacy today. It was the weekend, and it was slow, so we spent much of the day cleaning and organizing and pre-packing meds for the coming week. And Stan came by, drunk as a skunk, and wanted to “talk.” About what, I couldn’t determine. “America,” he said, leading me out into the hospital courtyard. “I want to ask you questions about America.”

“Ok…” I said, slightly apprehensive. It was not yet 10 o’clock in the morning and he was blitzed. “What would you like to know?” I asked. But he couldn’t really say, or if he did, I couldn’t understand him through his slurred speech. “But I must get back to work, Stanislas. Maybe we can talk on Monday when we are working together?” I suggested.

“Or maybe we can talk some other time, when you are not working, and I can ask you some questions,” he fumbled.

“Ah, but I’m afraid I will be working every day,” I said. “And I really must get back now. I’ve left Thomas all alone. I will see you on Monday?”

“Yah, ok, I will see you on Monday.”

“Be careful,” I said, then wagged my finger. “Don’t get into any trouble.”

“No trouble!” he grinned, and staggered away.

Sigh… poor Stanislas. Sometimes I hate when I’m right.

****

I worked until five, then went for a run before dinner; then worked until about 11pm on the mSupply project plan. Now that I’ve spent a week packing pills and dispensing scrips and shelving stock and whatnot, I feel like I’ve got a fairly good handle on the way things work. Now I’ll start digging more deeply into the actual software and figuring out the nuts and bolts of how each of the processes it manages works, what modules we’ll employ, what import files I’ll need to prep, and blah blah blah.

Day 7 – Sunday

Kind of a frustrating day today. Worked the morning at pharmacy, with Thomas again, which was cool, then met with Shelagh, which is always a hoot, because you never just “meet with Shelagh” when you go over there – you meet with Shelagh and Chiko and Jim and Josh, and play “What’s Your Favorite Movie” and “Can You Fix My Leggo Gun” while Love Actually plays on loop in the background (yep, aGAIN – or no wait, maybe that was yesterday…). Anyway, so I met with Shelagh to update her on where I am with the project and then spent the rest of the afternoon and the whole of the evening doing battle with the friggin’ internet. It’s only dial-up here (and at 500 kwacha a minute, friggin’ highway robbery), and I had to re-download the nearly 10MB user manual for the mSupply software because the one I had downloaded back in Lusaka disappeared off my laptop. Or expired or something, I don’t know. All I know is I clicked on the link for it on my desktop only to get a message that said “Sorry, this is not the user manual... To download a copy, visit our website” and blah blah blah. Anyway, so I needed the internet and it took me, I sh*t you not, no fewer than three hours to track down the key for the room, find a power adaptor (I managed to lose mine somewhere in the 50 yards between my house and the hospital), and configure my laptop for the connection. When I finally got it all set up, it took almost 25 minutes to load the first web page and then nearly five hours to download the damn manual and by then it was too late to do any work.

Tomorrow I meet with Shelagh, Ian and Jeremiah to review the workflow process as I’ve understood it and fill in any gaps, suss out the priorities for the next two weeks (I think I will end up staying for three total, instead of two – there’s just too much to do), and talk the issues/potential obstacles I’ve identified and brainstorm possible solutions. I’d hoped to have more prepared for them, but I’ll have to work it out in the morning, I guess.


Day 8 – Monday

Ok, it’s friggin’ cold here. I mean really friggin’ cold. Have I mentioned the cold yet? It’s freezing! I know it’s winter (and didn’t I say once that we’re at about 4,000 feet here?) but it’s sub-Saharan Africa, man – it’s not supposed to be this cold.

Anyhoo, so I met with Shelagh, Ian and Jeremiah and it went really well. I also managed to connect to the internet and shoot off the draft project plan to the mSupply developers in Nepal to get their feedback and their input on the best next steps to take, so it looks like we’re on our way. I’ll spend less time in the pharmacy this week and more time holed up at my house banging away at the plan. Weee!

Ooh, and I’ll also, when time allows, be doing some writing work for a small, newly-incorporated independent record label in New York – West Avenue Records. Their first artist is set to release his album at the end of July and I’ve been hired to help with copywriting and PR and whatnot. Check him out at http://www.michaelnappi.com/!