togo excursions

i was volunteering in togo through an ngo called world medical mission. while generally they are a great organization, they were super paranoid about not letting their volunteers use public transportation or even taxis, which is outrageous - as a result i am probably going to avoid volunteering with them again. on top of this, the hospital is in a very rural area without many nearby towns, so i didn't get out as much as i would have liked to. oh well.

i was able to go on a few daytrips on the weekends. on one saturday a group of us visited visited a nearby boarding school for blind children, run by the same mission agency as the hospital. it is very cool - they provide great education for the children (and even adults), who are mostly blind due to trachomatis flies, the most common etiology of blindness in africa. they are taught braille at the school, and there are textured posters on the walls of the school for teaching various things like topography on maps and different organ systems of the body. they are also taught how to weave furniture which they can continue to do once they leave to provide a service to their communities. there are some new missionaries running the center who are really doing some great work there. they also have an aquaponics farm they showed us, where they grow tilapia fish and use the waste to grow plants such as lettuce and strawberries. we then went to a french restaurant in kpalime called chez fanny, which was pretty good.

one sunday myself and some medical students climbed one hour up a nearby mountain to attend a church up there. we were soaked with sweat upon arrival so needed to change. despite being at the top of a mountain without electricity, each of the approximately 20 people who showed up were wearing their sunday best. they were very welcoming.  speaking of, its been nice having the medical students around - there have been 3 of them at any given time. one is going into pediatrics so i have been able to do some teaching and he has been very helpful around the hospital.

on our last weekend, we took a long drive and then a long hike to a very high waterfall right on the border with ghana. so despite my previous successful endeavor to visit ghana, got to step across the border again! we went swimming beneath the waterfall and the water falling hundreds of feet created a crazy wind tunnel of mist. it was great. 

there has been a lot of fomenting unrest in togo while we've been here, with widespread protests against the autocratic leader, faure gnassingbe. between him and his father, the family has been ruling togo since the 60s, and people are starting to get tired of it. compared to its immediate neighbors, togo is relatively poor - the reasons for this are of course multifactorial, but it is at least partially due to government mismanagement. there are weekly protests including in the nearby city of kpalime, which are generally very peaceful, but during some of which people have been killed by government security forces. this is part of a wider trend across africa right now, dubbed the "african spring."  my amazing wife ann is actually writing about this while here, so has been traveling around the region while i've been at the hospital.

lassa scare

about a week after arriving in togo, i examined a six year old girl who presented with about one week of fever, diarrhea, emesis, and diffuse abdominal pain. i didn't think much of it, and didn't use gloves, because they aren't really readily available in the clinic unless you go looking for them. i have been using them since. we did some blood work, and admitted her to the hospital. she tested negative for malaria and typhoid fever, the two most common etiologies of fever here. she also had significant pancytopenia (low white blood cells, red blood cells, and platelets), which is strange. we started her on the empiric antibiotic treatment for typhoid fever, but after two days she continued to have persistently high fevers, and her three year old sister also started developing the same symptoms. her sister was found to have the same lab results, and both also had very high transaminase (liver enzymes) levels as well. all these symptoms are consistent with viral hemorrhagic fever, specifically a terrible disease called lassa fever. to top it off, the younger girl started having profuse blood in her stool.

lassa fever is an arenavirus endemic to certain parts of west africa, spread by the aerosolized urine of a certain species of rat, which come into people's homes during the dry seasons. it can also be spread between people via any body fluids. it was first described in the 1970s, and was named after a city in northeastern nigeria where there was a major outbreak. it is a viral hemorrhagic fever similar to ebola and marburg virus, as in addition to the nonspecific symptoms of fever, abdominal pain, diarrhea, emesis, and throat pain, etc, it can also cause bleeding from mucosal membranes and hypovolemic shock and end organ failure. so pretty scary. it has even been cited as a potential agent for bioterrorism. about 80% of people who get it actually don't get sick enough to be hospitalized, but the mortality rate is about 50% for those who need hospitalization. even more scary, well over 50% of nosocomial infections (person-to-person in a healthcare setting) are fatal.

there had never been a positive case of lassa fever in this part of togo before, making it less likely. however, antibody studies have been done suggesting that the majority of togolese have been exposed to the virus at some point, meaning it exists and just hasn't been isolated, likely simply due to lack of testing. the first person confirmed to have died from lassa fever in the recent past who contracted it in togo was an american physician assistant who was working in a mission hospital in northern togo and fell ill last year. he continued to deteriorate, and was evacuated to germany, where he sadly died. they then discovered he had lassa fever. he didn't have any known exposures, so no one really knows how he contracted it.

after the girls had been sick for a while and after much discussion among the hospital staff, it was decided to send a blood sample to the central lab of the government in lome to test for lassa fever. it became apparent that it is quite the process. the local authorities have to sign off on the test being done after a meeting, and a medical provider has to escort the blood sample all the way to lome as it is considered biohazardous. this all took the better part of a week to arrange. once the blood finally made it there the confirmatory test by pcr was relatively quick. i read everything on the internet about lassa fever. interestingly, a number of studies about transmission in exposed, unprotected individuals came out of germany last year after the missionary from togo was evacuated to there with a yet unknown illness. there is an antidote of sorts, but it doesn't really work very well, and isn't exactly available on short notice to a rural hospital in togo.

thankfully, the test came back negative! i must admit though, in the intervening days i was quite scared that i might get it (and if i did, more likely than not, die an agonizing death). because the disease starts with nonspecific symptoms like sore throat, diarrhea and fever, i was constantly thinking that i might be coming down with it. i prayed more frequently and fervently than i normally do. it was an important reminder for me of the fragility of my life, and that they can end before we want them to, a reality that isn't as apparent in the west as it is in africa. i really needed to trust in God, and be reminded that my faith in Him is all i really have that matters, and all i really need. there are so many frivolous concerns in our lives that just don't really matter when you think you might die soon. thank you to my amazing wife who comforted me when i was really on edge. we still don't know what the girls had, but it was almost certainly something viral and nasty. thankfully they started to do better and we were able to send them home.

first weeks in togo

as an elective during my third year of residency, i am able to do a month of global health! i arranged to come to togo, west africa. i am spending one month at the karolyn kempton memorial christian hospital, also called hospital baptiste biblique (hbb). it is the second largest hospital in the country, and is a missionary-run hospital in tsiko, near adeta, togo, a rural area about 3 hours north of the capital lome. on arrival in lome, the hospital had arranged a redundant "welcomer" to meet us prior to customs. she directed us to the wrong line, and then when customs guards asked for a bribe for one of our suitcases, advised us to pay it. we refused, and they eventually let us through without it.

in togo, good medical care is very hard to come by, so the services hbb provides are much appreciated. people in togo must generally pay up front for any hospital services, including emergent ones, such that motor vehicle accident victims, even if obviously wealthy, are not resuscitated in emergency rooms until the medical providers are paid, leading to countless preventable deaths. widespread frustration over these practices are one of many drivers of recent protests against the autocratic government. hbb is unique in that they treat any presenting emergent patients first, then ask for payment later. they also supply medicines and supplies for inpatients, which contrasts with most hospitals in the country which require patients or their families to provide supplies and medicines, which they need to buy at markets outside the hospital. all the physicians at hbb are western missionaries (which makes it a good place to learn for a resident such as myself), though there are a staff of togolese physician assistants who see many of the patients in clinic and are the first call overnight. physicians, including myself while i am here, act more as consultants overnight, and do rounds on inpatients and see clinic patients during the day. everyone in the area are subsistence farmers, such that even just the meager salaries of the physician assistants and nurses have essentially created a middle class in the area. most of the locals are people belonging to the ewe tribe, which stretches across the west african countries of benin, togo, ghana and others. there are other tribes as well though, such as the fulani, who are more nomadic cattle herders and have their own language. they often come by the hospital, are told how much something like a small surgery will cost, leave, and come back a week or two later with the money, which is often a lot for this part of the world. we had one little fulani feeder-grower premature baby who had been there for weeks, requiring a special high-calorie formula and an incubator. every day it was someone's job to explain to the grandmother why the baby needed to stay until they reached a certain weight, because they wouldn't survive life on the road at their size.

i have seen some very interesting medical cases thus far. by far the most common diagnosis is malaria, which often causes severe anemia requiring blood transfusion and extreme splenomegaly. this is the diagnosis for well over half of the admissions. many children also get cerebral malaria which can cause confusion, seizures and coma/death. one of my patients died recently from this, likely a brain herniation. typhoid fever is also very common. one child had an intestinal perforation secondary to typhoid, which is not uncommon. intestinal amoebiasis is also very common, as are hookworms which are often visible just beneath the skin. impressively, the hospital has developed treatment guidelines for many of these prevalent conditions, so diagnosing and treating them as a tropical medicine novice has not been as challenging as i might have expected before arriving here. there are also a large number of developmentally challenged children who present to the clinic, some already many months old, who have never been diagnosed and have never seen a medical provider before. many have traveled long distances, often even from neighboring countries, to come the hospital because of its reputation. sadly, most of the time there is not much we can do.

a common theme of medicine in the developing world is that people just take longer to present, so their pathology becomes more extreme. i saw a boy the other day whose toothache one year ago developed into indolent osteomyelitis of his jaw, completely reforming the shape of his face over the last year. likewise, many cancer patients present very late with huge masses. because of the continued strong animism here, some children have scars from cutting attempts by local traditional healers for things like abdominal distension. many people also take "herbs" given to them by these healers, some of which the hospital staff are realizing cause liver failure and resultant uncontrolled bleeding. there are also many premature infants, often born via caesarean, many of whom die because there are no ventilators if they have respiratory distress. there is the capacity to provide non-invasive positive pressure, however, and it is amazing how well some of them do. there are other cool work-arounds, like giving premature babies nescaffe instant coffee powder in their feeds instead of pharmaceutical caffeine to stimulate their respiration!

mexico city!

in april i was lucky enough to be able to go to las vegas for the acep (american academy of emergency physicians) advanced pediatric emergency medicine assembly in las vegas, which was of course an excellent conference! on my way home to philly, i decided to take a flight detour through mexico!

i had a layover in monterrey, mexico, during which i was excited to check out the vip lounge that i suddenly had access to thanks to my new credit card, but it was excessively crowded, to the point of multiple people sitting on each other's laps.

i had 2 full days in mexico city, and it really hit the spot! great value for money, and a ton of things to do. i mostly just wandered around - huge, beautiful malls. there is a massive downtown park chulpuateca with many attractions including a colonial era castle with great views of the rapidly proliferating skyline, and, most famously, the excellent national museum of anthropology one of the best museums i have ever been to! it is arranged around an open courtyard, with an iconic roof that has water falling from it. in the surrounding building is a very thorough history and present-day synopsis of mexico's various regions, which are remarkably distinct from each other in many ways. a definite must see.

also went to the upscale polanco neighborhood which is where mexico city's wealthy jewish and lebanese populations reside and shop, and downtown zocalo square, the third largest square in the world, which also has one of the largest flying flags in the world. nearby is the torre latinamericana, one of the tallest buildings in mexico city, which has a great viewing deck on the top. also perused some cathedrals and the place bella artes which is mexico city's beautiful opera house, and the plaza girabaldi which is filled with mariachi bands at every time. and for the first time ever, on the flight home i got upgraded to first class!

graduation time!

my parents and sister came to visit for my graduation! we had the week priot to graduation off, so we spent the time traveling around israel/palestine which was a lot of fun. we stayed in a little hilltop village called shoresh just west of jerusalem, and traveled around via rental car which was amazing as i got to drive! western wall for shabbat sunset. cheap ethiopian food in downtown tel aviv. qumran caves on the shores of the dead sea where they found the qumran scrolls, the oldest copies of the old testament. floating on the dead sea. masada mountain, symbol of jewish independence. church of the holy sepulchre that marks the place Jesus was crucified. hiking through hezekiah’s tunnel – a 1.7km pitch dark water conduit that supplied the ancient city of david. shisha in jerusalem. nazareth. cana where Jesus performed his first miracle. tzfat, a hilltop ancient center of jewish mysticism/kabala and currently a magnet town for artists. random stop at mount meron to visit the much revered tomb of jewish mystic rabbi shimon bar yochai. mount of beatitudes and caperneum on the shores of the sea of galilee. tomb of the patriarchs (abraham and isaac) in hebron, palestine, and wandering the segregated “apartheid” and other streets of hebron’s old city and eating cheap chicken which was the family’s favorite day. church of the nativity in bethlehem. showing the family my clinical sites in bnei brak, kfar kama, afula, ashkelon and of course beer sheva. but its not about the places, it was about being with family which was so nice! thank you for coming:)

then it was time for graduation! our speaker was dr. ofri, a prominent writer and physician at new york university school of medicine. my friend ross gave a great speech, and then it was over. mazal tov/mabruk/congrats to my classmates; i wouldn’t have wanted to get through medical school with any other group of people!

last weeks of medical school

my last three selectives were radiology, otolaryngology and orthopedics, each for two weeks. interesting stuff, and quite relaxed schedule which is very nice!

i’ve also been able to do some things which were on my bucket list, like visit the israel museum in jerusalem which house the dead sea scrolls. beer sheva finally has its first ethiopian restaurant (there are many ethiopians here so it is surprising that it took this long for someone to open a restaurant). last weekend went to a hot spring spa called neve midbar in the negev desert south of beer sheva with some bros, as well as made one more trip to the taybeh brewery in the west bank, which i must say is one of my favorite locales in this part of the world, for what it represents. as glad as i am to be moving on, there are things about here that i’ll really miss.

healthcare in israel

israel has an excellent socialized healthcare system for its citizens, arguably one of the best in the world. early zionism was very idealistic and socialist, and quality and universal healthcare has always been a central theme. the current system uses an interesting model – it is single payer (the government), but there is an element of competition as well. there are three not-for-profit “sick funds” which receive a set monetary amount from the government for each citizen who is insured with them. the government requires that these funds provide a “basket” of medical services and treatments for their enlistees. for the most part, the basket includes what would be considered the standard of care in the western world. it generally does not include things such as procedures or treatments for aesthetic reasons or overpriced or experimental new drugs. typically only the generic version of a drug is covered as part of the basket if it is available. generous allotments for services like physiotherapy are also included in the basket. the lump sum payment to the sick funds for each patient, termed “capitation,” provides incentive for the fund to invest in preventative measures for its patients, as if they can keep them out of the hospital or prevent them from becoming sick in the first place then significant money can be saved. each fund receives money for their patients according to the same formula (age, gender, medical conditions, disability, area of the country in which they live, etc.). in addition to the required basket of services and drugs, the funds can provide additional services as well to attract more patients/customers. citizens can choose their sick fund and can switch between funds at any time at no penalty,, and the funds cannot refuse to insure a patient. the funds are also the operators of the hospitals and clinics, which technically keeps the government out of the business of healthcare though there is obviously close collaboration.

though required healthcare is free for the citizenry, targeted fees are permitted that aim to reduce inefficiencies. for example, due to the universal problem of overuse of emergency rooms for minor issues, a fee was introduced for emergency visits that are not either first referred by a primary care physician or do not result in a hospital admission. likewise, a large levy exists for those who call an ambulance but are not subsequently admitted to the hospital. these efforts of course sometimes result in further inefficiencies, such as people feeling the need to first contact their primary care physician when they should probably just go straight to the emergency department, or doctors admitting patients when they medically don’t need it to help them avoid the fees. overall though it is a very fair balance that allows everyone to get the healthcare they need without having to go bankrupt to do so, and attempting to limit unnecessary overuse of the system.

of course, socialized care has its limitations. while it is excellent for the poor, the rich do not appreciate waiting in line, getting a generic drug rather than the brand name one, or not being able to hand-pick their surgeon. thus, over the last few decades a robust private healthcare system has developed in parallel with the public one. the merits and drawbacks of these two-tiers are beyond the scope of this blog post, but private healthcare has become a major sector of the israeli economy and a very contentious issue for all involved.

prioritization of the family is a major focus. things like maternity leave and government transfer of money to parents is a priority, as it is a strategic goal of the government to keep the birthrate high. so much so that invitro fertilization for all israeli citizens is free, at tremendous cost to the state.

emergency medicine and disaster response are huge in israel. due to everyone spending required time in the military, most people have some training in responding to emergencies, and many have firsthand experience from wars they have fought in. israel also sends medical teams to major worldwide disasters, either privately or as a military delegation, and are world leaders in this regard.

it must be noted that healthcare benefits extend only to israeli citizens – not to asylum seekers living in israel or to palestinians, except official east jerusalem residents. still sounds pretty good though, right? israel has its huge problems, but overall i’d say healthcare is one of its gleaming achievements.