Ok, time for more work updates. I have to even out my adventuring blog posts with some war-on-malaria blog posts. Some of you must think I don't have a job, with the bias of my entries, but I assure you that my first six months have been dominated by malaria work. Most of my adventures have been weekend escapes, and as wonderful as they were, not to mention essential for life balance, take up just a fraction of my time. Rightfully so, since I am here to help Namibia eliminate malaria, which might take a bit of effort! Bring it on, parasites... here we go.Â
As hectic as its been (and at times quite frustrating), I really have been enjoying my CHAI malaria work. As I have mentioned in previous entries, my job is not all locked into office paperwork and politics, but has a healthy fieldwork component thrown in. This is obviously my favorite part, but also adds tremendous clarity to my projects and goals. The fieldwork is instrumental in building necessary knowledge, but more importantly, it provides the true context and perspective that is critical for our potential success. The added bonus is that it also allows me the opportunity to interact with a tremendous variety of people and to explore all parts of Namibia, especially the regions not on the tourist routes:
One of the most valuable field trips I have taken in my initial few months was my northern trek for our Diagnostic Algorithm Study. I have briefly mentioned this study in one of my early posts but here is some background information on the project, as well as a refresher on the Namibia malaria situation:
The country is on track to reaching malaria elimination by 2020. Excellent. One key factor in achieving this target is establishing an effective diagnosis system. If the health workers diagnosis malaria properly, then they can treat properly. Also the more accurate the diagnosis, the more able we are to prevent onward transmission of malaria. Diagnosis is a critical component of an elimination program not only to ensure good malaria management, but will also aid in the patient care overall (as malaria cases go down, fevers are attributable to other causes, and that 'differential diagnosis' becomes just as important).
Diagnosis is also the cornerstone for malaria surveillance. So, as Namibia pursues malaria elimination, the NVDCP (the office where I work, the National Vector-borne Diseases Control Programme) must implement the most efficient diagnostic algorithm (methodology) that will capture the maximum number of malaria cases. A more accurate, efficient, and fast response to identifying true malaria cases (in what we call, the passive surveillance system) will trigger active surveillance, where surveillance (or environmental health) officers trace the origin of the malaria case(s). With this, we aim to interrupt local transmission, limiting cases to importation from neighboring countries (with this, comes our cross-border work, but we'll save that for another entry perhaps). With this improved diagnosis and surveillance, we can actually map malaria risk and identify where the trouble spots are for malaria transmission. The Diagnosis Algorithm Study will also be used to inform and direct the new national diagnosis and treatment guidelines that we are developing.
All clinics in Namibia have stock of rapid diagnostic tests for malaria (RDTs) that can give an accurate test result in about 15 minutes. They are simple devices that just need a drop of blood and some buffer solution:
If used properly, these RDTs are the best diagnostic tools, especially in these rural clinics where microscopy is unavailable. For any result that is unclear, district hospitals do have microscopes for parasitological confirmation of cases.
Health care workers in Namibia have been dealing with malaria for decades, and are quite familiar with the signs and symptoms. When the malaria season is at its peak, and the clinics become over-burdened, some health care workers will treat for malaria just based on the clinic signs rather than using the RDTs to confirm if the person is truly positive. This is a big no-no and happens often in the high endemic regions, Kavango and Caprivi, where a lot of our work takes place.Â
Although all clinics have RDTs and all district hospitals have access to laboratory diagnostic services, an estimated 50% of suspected malaria cases are treated based on clinical suspicion, even despite negative test results. The over diagnosing prevents accurate reporting and determination of disease trends. This is also quite dangerous, as the true cause of illness goes undiagnosed and has been shown to increase the chance of death.
The aim of this study is to assess the ability and feasibility for the health care workers to test ALL fever cases for malaria.
 We also have these secondary objectives:
To determine the true prevalence of malaria in these 4 sample health facilities
To establish a list of common risk factors for having malaria
To design a testing algorithm in order to catch all cases with minimum cost
To understand the current diagnostic practices, outlooks, and challenges of the health facility personnel
We chose the four health facilities from three high endemic regions in northern Namibia; Kavango, Caprivi, and Omusati. These facilities were selected because of their representativeness of other government health facilities in the malaria-endemic areas and because of their high reported malaria caseloads. These clinics also seemed to be overburdened and their reporting has not been consistent, so it gave us an opportunity to visit, work with, and re-train the clinic staff. We could see where their problems persist, evaluate what they need to improve, and see what we can do to help.
On the trip, I would have âMemeâ (title of respect, 'Tate' for men) Haidula with me, the national case management coordinator for the NVDCP. She is based in our northern office in the second biggest city (town) of Oshakati. Haidula has been a nurse in the malaria program for over 20 years and is the veteran of the department. Her institutional knowledge is unbelievable, plus, Haidula has such a nice rapport with the clinic nurses. She definitely made my trip easier.Â
Since this project is under the Ministry of Health, we had to travel in the official 4x4. Sweet. I could have flown up north to meet Haidula there, but figured the ride up would allow us to get to know each other better and to have the chance to review the study protocol. I forgot to mention that the first leg of the trip was a 12 hour drive. Yikes. It would just be Haidula, myself, and the ministry driver Kiwasha. 12 hours. 6am to 6pm. Plenty of time to find out how we would get along on the rest of the study trip, which would last about two weeks. That initial drive turned out to be a great decision though, and by the time we made it to the first clinic, we were the best of buddies, which the health workers could immediately sense. The nurses had automatic trust and comfort with me, when they saw I had a good working relationship with Haidula. It was a tremendous advantage and allowed for candid dialogue with the nurses, and more accurate information for the study. I felt so lucky to have that connection established with them, and lots of credit to Haidula. A huge first step.
During those long trips, I had the chance to befriend our driver, Kiwasha, as well. We shared snacks, stories, and music. We would listen to his Herero mixes and then would switch over to my tunes. I tried to limit my music, because I thought he wouldn't want to listen it, but he actually kept asking for more! (He had Peter, Bjorn & John and Fleet Foxes on repeat. Too funny watching this old African man bob his head to those guys). A highlight to the drives without a doubt. Another road trip memory that sticks out in my mind is when Haidula offered me a âsnackâ she prepared. I said yes please, and then I see her take out a whole fish. Didnât see that coming. I of course didnât want to offend her right at the start of our time together, so there I was in the front seat of the ministry 4x4, eating a foot-long fish with my hands. Next, I washed it down with a lemon from her garden. Sure, why not.Â
As a matter of fact, most of the meals we ate were on the road, which gave me the chance to try some of the local fair. Here is Haidula, at a road side vendor loading us up. She knows how to find the quality items:
Here we bought some meat, spinach, and mahango. Mahango, or pap, is the traditional starch source for most northern Namibians, and is like a porridge. Like most starches it is as good as the sauce you smother it in. Kiwasha was our taste tester, and below, he is picking out some more fish.Â
Then a satisfied purchase:
For our travel route, we would go to the furthest clinic first, in the extreme Northeast of the country, in the small strip of the Caprivi region. This takes us basically to the heart of southern Africa. Like we do, hold out your left hand, palm flat and open, fingers pointing down and thumb sticking out to the right. That is basically the shape of Namibia, and the thumb is Caprivi.
I was really excited to get out to Caprivi because it is a real unique area of Namibia. The strip has its own distinctive history before and through Namibiaâs battle for independence. More on Caprivi when I have a more extensive trip there. This time around I was limited in time because of the tight clinic visit schedule.
Due to its northeastern location, wedged between the Zambezi and Kwando Rivers, Caprivi is more densely vegetated compared to its neighboring regions, which adds to its charm:
It was also exciting to see the village homes nestled between the trees:
The northeast of Namibia is filled with traditional homesteads having these characteristic thatched roofs. They were representative of the area, and I was impressed with their strong construction!
We left early in the morning, so we could try to reach Katima Mulilo, the Caprivi capital by sundown. You do not want to be stuck on the road at night in Namibia, it is definitely frowned upon because of the danger in hitting an animal. (Hitting a warthog at 80 mph is like crashing into a brick wall, and has totaled many vehicles here). This danger was intensified in Caprivi because of the dense vegetation and risk of larger animals crossing the road...
 As we entered the strip, we kept seeing warning signs for elephants. Midday you would probably not see any, since they will most likely be eating or drinking at a water source. But since sundown was approaching, there was a chance we could see some elephants crossing the street to go back to their home after their drinking and dining sessions for the day.Â
One of my favorite road signs, all along the strip:
I was on high alert and excited, but Kiwasha was not. He knows the true danger associated with the wild elephants, and if you crossed the wrong one, they have the strength to just toss the vehicle on its side. My eyes were burning, but on we drove and no sight of our giant friends. However as soon as we were ready to leave the thin strip to the district around Katima, we caught my favorite animals!
My first look at wild elephants:
It was a whole family, complete with some "toddlers". Kiwasha, was not going to hang around. We were already gambling with sundown, so had to keep moving. Still had the opportunity to snap some shots:
It was a special moment, and I think I will never get tired of seeing elephants in the wild. I think they are such amazing and dignified animals, I could watch them for days. Here is my last glimpse, at my first look at elephants in Namibia:
Another added bonus of visiting Caprivi, is that my good friend, Lande, is stationed in Katima for the Spanish Red Cross. I had the chance to crash at his place while up there, and to grab a beer on the edge of the Zembezi River (no hippo or croc sightings, but next time around!...). If we cant squeeze in a trip this month, next year Lande and I will venture over to Zambia and Zimbabwe to catch a glimpse of (and get drenched by) Victoria Falls. Canât wait, it is a must.Â
So, back to business. Our first health facility was Bukalo. This was located deep in Caprivi and was a big and busy clinic, servicing a large population. Â
On the map below, Bukalo is represented by the red pin furthest to the right. On this map, they actually label the areas at risk of flooding in blue, and you can get an idea of how much of the Caprivi tip can get submerged:Â
âBigâ clinic meant 3 observation rooms, a waiting room inside, and 3 nurses on staff. I liked the nurses instantly. They were so kind, inviting, and respectful. I was also quite surprised to see that two of the three nurses were males. Good for Namibia. There was actually a decent representation of male nurses I saw on my trip, and was happy to see this adopted and accepted in the country. How progressive. (Human resources is an extreme issue in Namibia, being the second least dense population in the world, and the health facilities need all the help they can get. One of the biggest deterrents to quality of care is simply the lack of health care workers.)
So first thing, after all our greetings, was to go over the reasoning for the study, why their clinic was chosen, and to review the protocol and methodology. We wanted them to feel proud that their health facility was chosen, that it will represent the whole region, and the information they would provide would not only help their individual clinic but all clinics in Namibia. They were definitely excited, and again, made my work that much easier.
We arrived at Bukalo on a Monday though, and that is definitely the busiest clinic day. To not disturb the flow of patients, we decided to come back early the next morning to do the practice rounds. These were a ton of fun, and the nurses were so attentive to the study protocol, I couldnât have been happier with their involvement. At Bukalo, with our extra time in the morning, we trained every nurse on the study and all switched being a practice malaria patient. Here is the head nurse, Meme Masurle, and nurse Jason going through a practice round:
We went through the mock visits, but also re-trained the nurses on using the RDTs. Here is Meme and Jason having fun with the training:
I would play the malaria patient most of the time, and canât tell you how many times my fingers were pricked those few weeks. They did a great job though, and at least I know for certain I donât have malaria!
Here is a breakdown on the study methodology:
Clinic attendees will be explained the study while in the waiting room. When the patients with fever or history of fever within the past 2 days come to see the clinic clinician they will be asked if they would like to take part in the study. If they agree they will sign or thumb print the attached consent form. All patients will have their axillary (armpit) temperature recorded. During the normal screening, the clinician will also complete a brief questionnaire including demographic data, malaria risk and history of the current illness. Following the questionnaire all patients will be tested with a RDT. The results of the tests will be noted in the case report form and the patient treated according to results. These RDTs were kept for us, in plastic bags with some silica gel beads to preserve the blood samples. Here is my colleague Stark laughing at our ridiculous task of pre-loading 500 bags with silica gel. This took us a whole afternoon, the week before I left for the trip:
We will have our colleagues at the University of Namibia investigate the RDTs, using some lab techniques to examine the parasite genome and to see which malaria parasite species we were dealing with, and also to serve as a quality assurance check on the RDTs, to determine if the patient was in fact positive or negative. Since we were using the patientsâ blood for further studies, we wanted to ensure the health workers began using consent forms, mostly as I way to explain to the patients what exactly the study was about and how their blood will be used. This is a common practice in the States, but definitely was an extra step for these clinics. We didnât receive any objection to this though, and the nurses had fun doing the practice rounds of the consent process. It was fun for me too, as the public health nerd!Â
Here is nurse Michael, and Haidula going through a mock consent process:
 Along with reviewing the protocol and practicing the study procedures, I would do a brief structured interview with the head nurse about diagnostic practices. The information gathered from the interviews will be examined to help identify barriers to diagnosis adherence and to estimate the additional capacity required to operationalize the "test all feversâ algorithm in this zone. I asked the nurses about their view on malaria diagnosis practices, their experience with malaria over the years, opinions of RDTs and their effectiveness, what they should do if the fever is not due to malaria, the structure of the work day, how many patients they see on average per day, if they feel over or under worked, if they receive pressure from patients to treat fever for malaria, etc. I would also do a quick rundown on what they look for during their examinations (signs and symptoms that would make them the most concerned for the patient), and would check the clinic for their supply of diagnostic tools. The interview process was one of my favorite parts of the study and I really enjoyed hearing the nurses' perspectives.Â
I canât be making comments on the results of this study yet, since we are still compiling the data, but what I can say is that I was quite impressed with the nursesâ malaria diagnosis knowledge, and overall skill. I think all the clinics main limitations came in differential diagnosis, i.e. handling fever cases that are NOT malaria. Sometimes this was simply due to not having the proper tools or support. A few clinics just needed basic items like stethoscopes to diagnose their patients properly when they are confirmed negative for malaria.
After our quick Caprivi trip, off we went to the neighboring Kavango region. This was another interesting part of Namibia, as its Northern border is aligned with the Kavango River, separating that side of Namibia from Angola. The capital is Rundu, which is right on the river.
For some reason, seeing this long body of water made it hit home that I was in Africa. You could see people on the shore washing their children, the vegetation was different, and the sounds were fuller with the calls of birds and animals.
I loved that right across the river was Angola. It was so close, I could hear the Portuguese being spoken by the women cleaning their clothes:
It was certainly a contrast to the arid countryside found in ž of Namibia. Not to mention, my lodge there had some amazing sunsets. My pictures cannot give this sun justice. It was such a giant red orb sinking over Angola, I would sit and watch its decent every evening:
I have guaranteed eye damage from staring too long. My pictures cant capture this experience, but hopefully you can get an appreciation of the colors and tone of the evenings I had in Rundu:
In Kavango we had our smallest clinic, and largest health center. These were hours outside of Rundu, in the middle of the Nyangana and Ndonga districts, at the top of Namibia.
Here are a few shots from the villages in the area:
For the Portuguese family: Como a ilha Terceira, hĂĄ mais vacas do que pessoas!
The heath center, Rupara, even had in-patient capabilities, an ambulance, and 6 nurses on staff at one time. This is the largest health facility for hundreds of miles. This setup is a massive machine. In complete contrast was our little Ndonga clinic. This was run by one nurse, our sweet old Kaulura. She has been working as a nurse for over 40 years, and was such a cute little lady. All smiles. This protocol was a bit overwhelming for her, so we gave her an additional visit to have some more practice. I regret not taking a picture, since she was one of my favorites, but it didnât feel appropriate in the moment. Maybe during my follow up visit this month, weâll see... One precious thing Iâll never forget, was how she reacted to our stipend we provided. When we said that her clinic was chosen and that we were going to pay her extra (each head nurse received a small payment from CHAI for their service and extra work that comes along with the study), she became emotional. She was so honored to be chosen, and was so thankful for the extra funds, that she began to cry. She thanked God of course, claimed He brought me to her. She wouldnât let go of my hand for the rest of the visit, which was tough for me, since all my friends know how much I talk with my hands. Wonât ever forget it.  She wants to do such a good job on the study, doesnât want to let us down, but I am already so proud of her work, just hope we can get Kaulura the extra support she needs. She sees, on average, 50 patients per day, in her little, one room clinic. This clinic just had space for her desk and the patient bed, and that is it. All the patients wait outside in a line, tolerantly. What a sight. She is completely overworked, yet did not complain, just stated it as a matter of fact. We are trying to see if we can get a rotation from the district to help her, at least on the busy days early in the week. Just by choosing her clinic for this study, Kaulura is getting noticed more at the district level, especially after we debriefed the local health department staff. No matter the results of the study, I feel good knowing she will receive a bit more attention and appreciation.
We closed on the Dx Algorithm Study with our trip to the Onesi health center in the Omusati region. This area I am familiar with, since it is close to the districts where I do my cross-border work with Angola, as well as a region I visited during the flooding assessment.
Onesi was another busy health facility with a great staff. Here it is, under a Namibian baobab tree:
 There was a nice young nurse from Kenya stationed there who had worked with CHAI on an HIV project in East Africa. He was happy to be a part of another CHAI study, and hopes to go to school for epidemiology! He was full of questions, and I really enjoyed his enthusiasm. It reminded me of my first spark in public health and felt good to encourage him.
The head nurse, Mary, was such a lovely lady and she worked outside the box. She even had her own mini project, where she would teach mothers how to grow and cook the local foods. I was so impressed, and she felt proud. She deserves credit for showing initiative.
Here is a picture of Meme Mary with her teaching sample jars:
Onesi so far has had the most fevers in the last few months, at 82, but only 3 positive for malaria! So far so good. We expected low numbers during the last few months, because it was the winter low season. Now as the temp rises, we will see more cases. This study trip was in July (told you I am behind on these posts) which was in the middle of the Namibia winter. As I just mentioned, this is the low malaria season but we decided to begin the study at this time so that we can give the nurses proper training when their days are less hampered with cases. By the time the height of the season would arrive, they would have a good understanding and comfort with the study protocol. Another benefit of starting this study in the winter, was to show the clinic nurses how many fevers will come in that are NOT malaria.Â
This trip was long with all the driving (I think we drove about 2000 miles, over 3000 Km, in one week) in between each region, visits to the district offices for preliminary meetings and debriefings, not to mention the actual time to reach the clinics. At the minimum, we spent one full day at each health facility to observe the patient care, perform our interviews, do the practice rounds for the study, and to assess their diagnostic tools and capabilities. It was an exhausting trip, but completely worth it.
I only had a chance to see 4 clinics during the Dx Algorithm Study, so very hard to generalize to all clinics in Namibia. Some could be doing better, some could be doing worse, but it least it gave me another opportunity to experience Namibia's health care system first-hand. The knowledge I gained from that trip has already been so valuable and will continue to influence my next steps here. This month and next I will be conducting another similar diagnosis study in some new clinics, and as this gained knowledge helps guide my personal public health growth, it will more importantly help steer the national malaria program in the right direction and to help us chose the right projects and interventions that will lead to the greatest impact in malaria elimination. I hope this post gives an idea of the kind of work I am dong here. We will have many more similar field trips, but this will hold the greatest weight for me. It was my first exposure to the Northeast endemic zones and the first time I was really directing a study. A special moment for work, and life, and I look forward to the next battles against malaria.Â
"Much good work is lost for the lack of a little more."
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