Sunday, January 17, 2010

A belated update

We are almost done with the malnutrition treatment training workshops!
Everyday has been very busy, but rewarding nonetheless. There are
constantly new things that come up! Our daily schedule consists of 4
to 6 one and a half hour workshops. We wake up around 7 am, have
breakfast around 8 am, and generally begin the training sessions
around 8:30 am (followed by 4 other sessions throughout the afternoon
and late evening). Our final lesson is at 9 pm for the nurses on the
late evening shift. Dr. Keri has also been training the doctors and
the clinical officers. It has been a very full three weeks here!

In addition to the workshops, we have also been spending substantial
time reaching out the community health clinics. Today we trained the
North Kigezi Health Center, the third of the three local health
clinics, on the diagnosis and outpatient treatment of malnutrition. We
were so appreciative of their enthusiasm and support of the program
and training sessions. We delivered hand-laminated Middle Upper Arm
Circumference (MUAC) Bracelets and we are currently building them a
stadiometer to help them make diagnoses based on weight and height.
Knowledge is so empowering. With an hour and a half training session
on how to read the Standard Deviation chart, they were able to make
diagnoses of malnutrition based on weight and height.

We also recently completed a detailed cost analysis that convinced Dr.
Ronald, the administrator in-charge of the hospital, that the
programme model is both sustainable and scalable. The average
malnutrition treatment for a child costs around $1 per day including
the costs of high energy milk, antibiotics, micronutrient supplements,
in-patient surcharges, etc. Average in-patient treatment period is
about 14 days. For less than $20, we can bring a severely malnourished
child (less than -3 SD of weight/height) back to health (> -1 SD)!

Power and internet have been sporadic in the last few days. This post
has taken us a few days to finally send.

Sunday, January 10, 2010

Our child malnutrition treatment program is getting off to a great start! The nurse practitioners, nurses, and other healthcare providers in the hospital have been so enthusiastic and eager to participate in our lectures and the hospital has been very supportive of the program. Even the nursing students, who are not required but still encouraged to participate, voluntarily came to the lectures. Their enthusiasm gives energy and life to our lectures and we are really enjoying teaching and interacting with them.

One afternoon, after the lecture on how to properly measure and weigh a child, we heard that the pediatric ward’s nurses were excitedly measuring the babies with the stadiometers and scales we have brought. We went down to the ward and watched them carefully measuring the babies. They were able to remember most of the key points with a few reminders from us. With review and practice, combined with their eagerness to learn, I am sure they will be able to master the concepts really well.

For mothers whose children are malnourished, we made a handout for outpatient nutritional therapy that has drawings of several high-energy snacks. Next to the drawings, we wrote the food names in Runyankore with help from Christine, one of the exceptional nursing students at the Karoli Lwanga School of Nursing and Midwifery. When we showed it to one of the mothers, she understood it and told us that it was very helpful. The following day, Ronald, the head administrator of the hospital, allowed us to make 500 copies for the nurses to give to malnourished child’s mothers. We also taught the mothers how to make F100 milk for severely malnourished children. We gave the lecture in the empty room that they granted us for the malnutrition treatment program. Thanks to a Mukasa’s kind help with translation, we were able to communicate with the mothers and answer their questions.

We also spent part of the afternoon laminating the Middle Upper Arm Circumference (MUAC) bracelets that we printed. Instead of laminating them in town, which is more expensive, we put duck tape on one side and clear tape on the other side to make the bracelets sturdy and sustainable. We spent quite a bit of the afternoon cutting and putting them together!

We have settled into a daily schedule of having three to four workshops a day. In between these workshops, we are working on finding ways to make our program sustainable.

We have lots of work to be done! I’m so excited!

Tuesday, January 5, 2010

We hosted our first workshop early this morning for the ER nurses, and it was a success! This is the first of many workshops that will be taught over the next two and half weeks. Using the projector that Dr. Burke provided us, we transformed our guest house living room into a seminar room for interactive learning. The beige colored wall worked perfectly as a screen, and the slight discoloration and crack on the wall embellished the powerpoint slides as an vintage background. We also utilized the dining room table as a station to practice using the infant scales and stadiometers. Several doctors - our mentors and new friends- sat in on the workshop to provide support! The workshop went just as planned. We were able to borrow a child from the Pediatric ward for the demonstrations and training.

We spent the rest of the day in and out of the Pediatric ward, working with the nurses on translating the outpatient nutritional plan into Runyanchuri and pictures that mothers can more easily understand. Christine, one of the star nursing students in the ward, helped us tremendously and taught us many words in the local language. She was so cheerful and enthusiastic about the malnutrition program. Without even attending the workshop today, she had read many parts of the protocol on her own time and even hand-copied some of the patient forms in the protocol for Bless, a malnourished child who was admitted today. In the afternoon, we met with Ronald, the head doctor in charge of the hospital. He was very receptive of our long term goals and proposal for the summer and offered his advice and help on our current goal- creating an inpatient referral center for malnourished children at Nyakibale.

In the late afternoon, a rainstorm came through the area. I opportunistically took the chance for a cold, natural shower since there hasn't been running water since our arrival. However, failing to realize that the water running off the roof was actually brown, I initially got myself muddier. After some more washing, loud thunders and lightening hastened and ended my shower early.

Nyakibale is located in a hilly region a little south of the equator. Although it is summer here, the altitude cools down the temperature significantly. Rainstorm is a daily occurrence in the afternoon. Goats and cows are often spotted off the roads grazing on the lush, green hills. I love this place dearly.

A Few Pictures from Nyakibale!

Monday, January 4, 2010

Arrival at Nyakibale

We've arrived at the Karoli Lwanga Nyakibale Hospital and it has been an eventful day and a half.  The Rukungiri district is absolutely beautiful and the Nyakibale community has been so warm and welcoming.  We arrived around 7 pm on Sunday and spent the evening at the Emergency Department (ED), a part of the MGH Center of Excellence for Emergency Care, with whom we are partnering to implement the Malnutrition Treatment Program. 


We whimsically ended up spending the evening shadowing the doctors and nurses in the ED – we were having a staff meeting after dinner when Drs. Mark Bisanzo and Keri Cohn were called in for an emergency.  There was a 3-year-old child, who had aspired corn into his lungs and obstructed his airways.  As there were no suctions available, Keri instructed the father to suck on a tube to get the corn meal out.  It was truly remarkable to see the father do this. I was moved by both the father's persistence, as well as the caring doctors who were instructing him along the way.  Although it was past 10 pm, and the ED was officially closed for the evening, we found the staff voluntarily working past midnight to attend to all of the patients.  The passion and commitment that I witnessed was inspiring; I look forward to working with each and every one of them in the following weeks! We spent the rest of the late evening establishing concrete goals and a plan of action for the Malnutrition Treatment Program for the month of January (please see below!) 


This morning, we woke up refreshed and excited for our first full day at Nyakibale.  We toured the hospital compound, met the rest of the staff at the ED and Pediatric Ward, unpacked medical supplies, created a lecture schedule for the 29 total workshops that we will be teaching, and went into town to purchase necessary supplies for the workshop curriculum.  Tomorrow, we have our first workshop at 8:30 am on Measurements and Monitoring Progress of Severely Malnourished Children.  We will write again soon!



Initiative to End Child Malnutrition: Goals & Plan of Action

Initiative to End Child Malnutrition

January 2010: Goals and Plan of Action


Massachusetts General Hospital Division of Global Health and Human Rights

Harvard College Global Hunger Initiative



 (1) Establish a referral center for the treatment of severe malnutrition at Nyakibale Hospital.


We will train the following groups on:

Emergency Department (ED):  

Nurse Practitioners

  • Diagnosis of severe, moderate, and mild malnutrition (including correct use of scales, and stadiometers, and reference charts)
  • How to use CARDEX/ORDER forms (and why)
  • Preparing RESOMAL and ½ darrows solution
  • How to identify complications of malnutrition and implement their treatment.

Outpatient Department (OPD):

Clinical Officers

  • Diagnosis of severe, moderate, and mild malnutrition (including correct use of scales, and stadiometers, and reference charts)
  • (patients are admitted by the OPD and treated in the ward)


Pediatric Ward


  • Diagnosis of severe, moderate, and mild malnutrition (including correct use of scales, and stadiometers, and reference charts)
  • How to use CARDEX/ORDER forms (and why)
  • How to prepare RESOMAL/ ½ darrows solution (and how to use)
  • How to make nutritional foods; teaching mothers via workshops
  • How to assess that the protocol is carried out (including daily recordings)
  • How to assess nutritional progress of child, including fulfilling requirements for discharge
  • How to identify complications of malnutrition and implement their treatment
  • How to identify complications of the treatment of malnutrition and implement their treatment


Doctors (that make rounds in the Pediatric Ward):

  • Diagnosis of severe, moderate, mild malnutrition (including correct use of scales, and stadiometers, and reference charts)
  • How to use CARDEX/ORDER forms (and why)
  • Assess that the protocol is carried out, and assess nutritional progress of child, including fulfilling requirements for discharge.
  • Identify complications of malnutrition and implement their treatment.
  • Identify complications of the treatment of malnutrition and implement their treatment.


Community Health Clinics:

Health Clinic Workers

  • Diagnosis of severe, moderate, and mild malnutrition (including correct use of scales, and stadiometers, and reference charts)


(2) Develop an outpatient treatment plan and training for moderate and mild malnutrition

  • [Secondary Goals for future]
  • Identify malnourished children in the community (via community health workers, health clinics, outreach programs, school programs)
  • Establish an outpatient center for the treatment of mildly and moderately malnourished children.
  • Troubleshoot barriers to adequate nutrition in the community.




Workshops/Training Sessions that will be taught:

Workshop 1: Measurements and Monitoring Progress


Workshop 2: Admission and Discharge Criteria, Procedure upon Admission to the Hospital


Workshop 3: Therapeutic Treatment Guidelines


Workshop 4: Nutritional Therapy Guidelines


Workshop 5:  Cooking various forms of high energy milk for Nutritional Therapy


Workshop 6: How to cook High Energy Rations, Resomal, and Darrow's Solution for the Nutritional Therapy


Workshop 7: Potential Complications of Malnutrition and Looking out for Specific Conditions


Workshop 8: Role Play: Teaching Mothers about Nutritional Therapy


Workshop 9: Outpatient Treatment of the Mild to Moderately Malnourished Child





Tentative Schedule of Workshops:


ED Nurse Practioners:

·         Will be taught five 1.5 hour sessions

·         Workshops 1, 2, 3, (4, 5, 6 combined), 7


OPD Clinical Officers:

·         Will be taught two 1.5 hour sessions

·         workshops 1, 2


Pediatric Ward Nurses:

·         will be taught all nine 1.5 hour sessions

Pediatric Doctors: 

  • will be taught five or six 1.5-hour sessions
  • Workshops 1, 2, 3, 4, 7, (9)

Community Health Clinic Workers

  • Will be taught two 1.5-hour sessions
  • Workshops 1, 2



Friday, January 1, 2010

Day 1: Pre-departure

Happy New Years everyone!

Despite not getting much sleep traveling back to Boston from the West Coast over the night, I am wide awake and excited about the upcoming trip. We are set to depart for Kampala, Uganda at 7 pm from Boston.

Over the past two months, we have been working closely with Dr. Keri Cohn on translating the child malnutrition treatment protocol into a series of interactive workshops that we will teach to the nurses at the Nyakibale Hospital as well as to community health workers in nearby communities. Keri has very patiently mentored us in the preparation of the teaching curriculum, as well as helping out with the logistically planning of the trip. Although we have finished our teaching curriculum and completed the workshops' powerpoints, Keri and Prof. Burke advised us to be flexible and expect changes to be made once we start teaching the workshops. Despite the extensive preparations, I still feel a slight unease whether I am fully equipped or capable of being a teacher.

As Rukungiri is the poorest district in Uganda and Nyakibale is the only hospital in the district (serving over 300,000 people), the resources at Nyakibale are extremely limited. On this trip, we are bringing over many basic equipments, such as infant scales, stadiometers, and even measuring cups for the Pediatric Ward and the Emergency Department. At first, I was surprised to learn that the hospital was lacking basic equipments, as they are so essential and fundamental to the daily operation of a hospital. We were very lucky to have many of the equipments donated to us - mostly from Keri's family members!

Keri also told us to be prepared for hurdles along the way.  Occasional power outages sometime necessitate the use of headlamps inside the rooms of the hospital while treating patients. Fortunately, the affiliated nursing school nearby allows for internet access, although slow and intermittent. We will try our best to keep up with the blog and post pictures of the trip!

Over the next 18 hours, we will be mostly flying, stopping briefly in London, before arriving at Kampala tomorrow night.