Where There Is No Oncologist – Angola Day 14

July 17th, 2019 by INMED
Posted in INMED Training Sites In Action|

This young woman arrived at our emergency department with a mass growing within her right knee for about six months. It was not painful, but the resulting weight and leg weakness made walking impossible. Her family brought along a very poor-quality x-ray, which nevertheless showed multiple egg-shell-like layers of calcification surrounding the joint – quite characteristic for osteosarcoma, a bone malignancy.


Cancers in this part of Africa her frequent: skin cancers, breast cancer, lymphoma, and cervical cancer are especially common. But mature diagnostic capabilities, such as PET scanning and histo-pathology, or unheard of in the nation whose national health expenditure is on the order of $180 per person per year. And therapeutics, which are often successful for osteosarcoma, are sparse.


That evening, we gently explain to the young woman and her family the gravity of her cancer, and that the only therapeutic option was amputation of her entire leg. Even then, we could not guarantee that her cancer might recur at a different location. They became very quiet. The following morning when I return, her bed was empty. In a land where there is no modern oncology, family had already taken her home.

What Is The Leading Cause Of Death In Africa? – Angola Day 12

July 15th, 2019 by INMED
Posted in INMED Training Sites In Action|

Helena, this four-year-young girl, arrived in our emergency department last night. Her parents explaining that for one week she had been coughing, running fever, eating poorly, and making wheezing sounds with each breath. First assistance, as is common in this culture, was provided by a traditional healer. But with no visible improvement, the family caught a public bus here to CEML Hospital.


Often, our patients arrive very advanced diseases and complex histories. This girl, by contrast, had a short duration of illness and classic physical signs: fever to 38.5 degrees, respiratory rate of 60, oxygen saturation 85 percent, rales and wheezes on chest exam along with intercostal muscle retractions.


To make a correct diagnosis, in addition to history and physical exam, some knowledge of epidemiology is very useful. In our world’s poorest nations, pneumonia is by far the leading cause of death. Poor nutrition, low vaccine coverage, and difficult access to emergency medical care compound the risk of these deaths.


With all evidence pointing to pneumonia, we proceeded with basic pneumonia treatment: hydration, oxygen, ceftriaxone IV, albuterol/salbutamol inhalation therapy – and treatment of her coexisting malaria infection. This morning, Helena appears more alert, with less wheezing, and less likelihood of succumbing to the leading cause of death on the African continent.

Recognize This Infection? – Angola Day 10

July 13th, 2019 by INMED
Posted in INMED Training Sites In Action|

This twenty-year-old man traveled from Luanda, the capital city, because he heard we have a dermatologist. While this is not true, I have special interest in tropical diseases, and I was impressed with his account: numerous painful leg ulcers that persist in spite of antibiotic treatments. His lesions bear resemblance with leshmainasis – a protozoal disease transmitted to humans by sand flu bites. Additional clue: this patient enjoys the Angolan beaches. In addition to mucocutaneous disease, Leishmania protozoa can also cause visceral disease (Kala-azar) with fever, weight loss, hepatosplenomegally, and anemia. Left untreated, visceral leishmaniasis is usually fatal within months.


Diagnosis is made by serologic tests or by identification of the organism from liver, bone marrow, lymph nodes, or the margin of cutaneous lesions. Unfortunately, we have no such diagnostic capabilities at CEML Hospital. Rather, I embarked on a presumptive trial of therapy, prescribing for him the oral medication miltefosine, He’ll return in two weeks for assessment of whether or not his treatment is effective. Stay tuned for a real-time tropical dermatology update!

What Is This Disease? – Angola Day 8

July 11th, 2019 by INMED
Posted in INMED Training Sites In Action|

This twenty-five-year young soldier arrived today with a perplexing story of a motorcycle wreck and low back injury two years ago. He fully recovered. Then, one year ago he began again to have low back pain and developed gradual angulation in his lumbar spine. He has not had cough, fever, nor any significant weight loss. As is typical in Angola, he received consultations at a number of health posts, and was prescribed a variety of analgesics and antibiotics without improvement. On exam, he has no back tenderness, can touch his toes, has a normal chest exam, and normal CRP laboratory results.


The above image shows the angulation in his lumbar spine, and corresponding findings on lumbar X-ray. What do you see? What is the most probable diagnosis?


The history of motorcycle injury and back pain is not likely related, given that he completely recovered. And, his recurrent back pain and progressive spine angulation one year later was slow in onset. Another important clue from the history is that a family member in his home is being treated for tuberculosis. Most likely, this man is suffering from tuberculosis of the lumbar spine, causing to collapse of the L 2-3 vertebral space, highlighted in the red circle above.


Extra pulmonary tuberculosis most often infects cervical lymph nodes, weight-bearing bones, and kidneys – all of which sport the presence of high oxygen tension necessary for TB growth. One outlier in this case is the normal CRP Laboratory finding. CRP is usually elevated in cases of tuberculosis.


How would you manage this patient? TB culture from extrapulmonary sites is rarely positive, and in Angola we have no TB culture facilities. His diagnosis is at best presumptive. Treatment will be immediately initiated with four anti-tuberculous medications. And what of the orthopedic injury? No corrective surgical procedure is available in our low resource setting. But the reassuring news is that his deformity is not likely to progress, and in this we are quite satisfied.

Not-So-Complicated Obstetrics – Angola Day 6

July 9th, 2019 by INMED
Posted in INMED Training Sites In Action|

“The baby delivered four hours ago, but the afterbirth is stuck!” explained our nurse midwife. She was frazzled and fatigued, being on her feet with this delivery for the entire night. At 5:00am, the new mother spiked a fever and began bleeding from her uterus.


When I arrived, a quick exam revealed her placenta was still attached to the inside of her uterus. Retained placenta is a well-known risk of pregnancy. If it continues, women develop bleeding and infection leading to sepsis. With treatment, this a not-so-complicated obstetrics. But without treatment, death is commonplace.


With a bit of anesthesia, I placed my entire hand into the vagina, and then up through the cervix into the cavity of her uterus. Unlike the rough, firm texture of the uterine muscle, a placenta feels like jelly. I encompassed the slushy placenta in my grip, and slowly extracted it with one pull. The midwife sighed with relief, and the mother gave a shout of joy.


Labor pregnancy continues to needlessly kill some 100,000 women each year, almost entirely in poor communities. One of our highest priorities at INMED and at CEML is to training healthcare personnel with basic obstetric skills such that no woman dies from not-so-complicated obstetrics.

Day In The Life: Assuredly Intriguing – Angola Day 4

July 7th, 2019 by INMED
Posted in INMED Training Sites In Action|

Most medical professionals – and broader society as a whole – honor exquisite specialization. Should I ever require a complex surgery, I will surely an seek out an such expert. But in locations like Angola, we simply do not have the resources nor personnel to justify narrow specialization. Instead, skill to manage a broad range of health conditions is not only required by the logistics, but is also intriguing to me. With this background, here are just a few of the patients I cared for today:


• 3-day old with pneumonia and respiratory distress

• 30-year-old with an intestine perforation and acute abdomen

• 70-year-old with heart failure and a cardiac arrest

• 10-year-old unconscious from cerebral malaria

• 45-year-old lady with abdominal pain and newly diagnosed malignancy

• 35-year-old with TB and bilateral pneumothorax

• 28-year-old motorcycle wreck and skull fracture


So far today, I have not seen any obstetrics, orthopedics or ENT. But several transports just arrived in our emergency department, and the closest qualified obstetrician or orthopedist is 750 miles away. Day in the life of an Angola doctor: assuredly intriguing!

What’s Your Diagnosis? – Angola Day 2

July 5th, 2019 by INMED
Posted in INMED Training Sites In Action|

This seven-year old arrived at CEML Hospital draining pus from the outside length of his thigh. This drainage, accompanied by painful walking, began about two months ago and persisted in spite of oral antibiotic therapies prescribed at various health posts. He has no history of trauma, and his growth and development were normal prior this illness. His diet is chiefly corn meal and vaccination history is uncertain.


What do you discern on this X-ray of his hip and femur? Several important finding appear. The femoral head, normally round and fitting snugly into the acetabulum, is destroyed. The shaft of the femur has multiple low-density “holes,” And, the lower shaft and its periosteum is much thicker than normal, especially inferiorly.


What is your diagnosis? Throughout southern Africa, osteomyelitis is tragically common, and in children is usually via hematogenous dissemination rather than trauma. Research is lacking, but sickle cell disease, malnutrition and malaria appear to be consistent risk factors.


How would you treat this child’s pelvic/femoral osteomyelitis? A prolonged course of oral antibiotic alone is not effective. The infected bone must be surgically debrided, drained well, and followed by antibiotic therapy.


Want to learn more? Come join us for an INMED Service-Learning experience via the Professional Diploma in International Medicine & Public Health. Your diagnoses and care for such children will thereafter be much more certain.

Will Saving Poor Children Lead to Economic Decline?

June 28th, 2019 by INMED
Posted in International Public Health|

This is vexing question is especially relevant today. Perennially, people have expressed concern that population growth would lead to doomsday scenarios in which jobs, fuel, and food supplies run out. In his 1798 book An Essay on the Principle of Population, economist Thomas Robert Malthus predicted that increasing population ultimately creates economic decline, and inspired Charles Dickens A Christmas Carol. Since that time, population control efforts have expressed themselves in many ways: restricted social safety nets, curtailed funding for international development, and approaches to foreign policy.


Truth be told, strategies that involve coercing women not to become pregnant, and “letting children die so they do not starve later” are not only unconscionable, but they are also not effective. Today’s research actually demonstrates: Countries with the highest child mortality also have the fastest-growing populations and worse economies. And, countries where children rarely die also have the lowest population growth and best economies. In other words, the parallel between birth rates, child deaths rates, and poverty is very close, whether these rates are all high or all low.


Today I depart for Angola, my seventeenth summer at CEML Hospital. This nation in southern Africa is home to the seventh highest birth rate in the world, and the fifteenth highest child death rate – just under that of Somalia. Bleak, but not as bleak as before. With better nutrition, child vaccinations, and civil conflict control, I’ve been privileged to witness how both child births and deaths are coming down, while simultaneously almost everyone has acquired a cell phone.


Are you curious for more? Enjoy this 3-minute video as Hans Rosling illuminates how saving poor children actually improved life for everyone.


What Strategies Save Our Poorest Children’s Lives?

June 21st, 2019 by INMED
Posted in International Public Health|

In only three-years, the Muso project witnessed dramatic gains in child health

In Mali, a desert nation in West Africa, preschool children frequently become ill and die from pneumonia and diarrhea. Into this despairing situation came Project Muso to solve root causes of health problems. The Project supplies education, community organizing capabilities, and management skills to enable community members to overcome the conditions of poverty that cause disease.


The success of this project has been remarkable. The service population area in Mali covered approximately 11,000 children under the age of five. At the start of the project, the rate of child mortality was 155/1000 births. Just three years later, the rate of child mortality had dropped by almost ten-fold, to 17/1000.


For newborns, the issue of timing is especially critical. Significant improvements in newborn survival can be anticipated when a system ensures that women reach a suitable birth center for delivery. A suitable birth center is one where: skilled care is available at every birth, premature infants can be supported properly, and sick newborns in the community can be identified and provided with care rapidly. Best practice stories, such as Project Muso, offer great hope. We are capable of better protecting the most vulnerable children on the planet. One community health worker put it this way: “Opportunity is like being pregnant with success for the health of mothers and children.”

Today’s HIV Focus And Concern

June 14th, 2019 by INMED
Posted in International Public Health|

In 2017 (the latest data available)…


  • 36.9 million people globally were living with HIV
  • 1.8 million were children (<15 years)
  • 75 percent of HIV-positive people knew their HIV status
  • 21.7 million people were accessing ART
  • 1.8 million people became newly infected with HIV in 2017
  • 940,000 people died from AIDS-related illnesses
  • TB remains the leading cause of death among HIV-positive people


Worldwide, the incidence of new HIV infection has declined 18 percent since 2010. But the HIV epidemic continues to be a serious threat. Incidence is increasing in North Africa, Eastern Europe and Central Asia. And in sub-Saharan Africa, women and adolescent girls are especially vulnerable. 1,000 become infected every day.


Even more concerning is that in the face of growing complacency, social stigma, decreased government interest, and reduced funding for research and treatment, experts are warning of a resurgence of AIDS. The virus still a public health danger, especially in hard to reach communities and among people who are at greatest risk.