Back in the Groove/Back on the Blog

After a chaotic start to my travels with a 4-hour delay in Vancouver resulting in less than one hour to make a connection to Johannesburg in London (which our bags did not), I (Paul) have returned to the blog. Those who have been avidly following along will recall that this is my third sojourn to Karanda Mission Hospital, now 2 & 1/2 years since Lori, Rachelle and Thea were here. This time I linked up with the team that Dr Ray Markham puts together annually to visit Zimbabwe. It was Ray and his office staff who initially installed the electronic medical record (EMR) Medical Office Information System (MOIS) at Karanda, at the request of their administration. My first visit in 2015 was inspired by a slide presentation I heard Ray give at a conference in Montreal and he had then encouraged me to continue the MOIS install.

I always have some trepidation when encouraging others to embrace computer technology in their work (particularly healthcare) as I am fully aware that it takes immense time and effort for people, especially those on the front lines here who are extremely busy. Thus each time I have returned to Karanda I am curious to see how much training has been retained and which features of the system are still being used given the demands of working here, not the least being the erratic power supply.

Once again the staff of Karanda have excelled. Some may recall that most of our efforts last time were to try and remove the need for the multiple accounting ledgers that were being used to record information, which some staff member then had to trawl through to extract the data required by the Zimbabwe Ministry of Health. Thus it was particularly gratifying to see that each department with MOIS was still “off book” except for the subset that the Ministry requires in a particular ledger (essentially HIV and TB). It was also incredibly gratifying to see the rapid and almost effortless way the staff were then able to extract the data they needed to (in a minute or two versus hours). Well almost effortless as there was a tiny (but extremely annoying) bug because of Canada being “Letter” and Zimbabwe being “A4” for printers. However after a few hours of: “I should remember how I fixed this!!” I did indeed remember.

It was also heartening to see how the staff adapted some of the workflows I had started. In some cases, they figured out that my way wasn’t working and so they came up with a better, simpler way. As usual everyone greeted me very warmly and generously, despite me being the “MOIS doctor”. It has been wonderful reconnecting with people and they are very patiently re-teaching me all the Shona I had forgotten.

Of course there have also been some hiccups. During this visit, we updated MOIS and, as expected, the update “broke” a few of my workarounds. Nothing I wasn’t expecting and the update now gives me the tools to do the local adaptations properly. However it does mean the keyboard grunt work has to be done. I do have the luxury of doing this in the computer room which is air-conditioned, unlike the other hospital departments and wards. As before, MOIS staff back in Prince George have endured my numerous requests and given me solutions.

This time of year is the rainy season and therefore “cooler” than the 40 degrees we all experienced in Oct 2016. However the fans are still required in the day and are missed when the power goes out. It does get a fraction cooler at night and I commented that this time was the first (on one night) that I actually had to pull up the bed cover. The difference in the vegetation is fascinating to see after the rain, with everything that was brown before now green. However the rains have been less than usual and the season appears to have finished early, which does not augur well for the coming dry. Already the water is being turned off at various times.

Because of rising prices, the hospital has even fewer medications available than before. For this trip, Lori arranged a substantial supply of medications through Health Partners International of Canada (HPIC). Something as basic but as essential as acetaminophen was being rationed before our arrival and the various antibiotics in the HPIC boxes were particularly appreciated.

Tania Bell, a wound and ostomy care nurse at Fort St John Pharmacy and Wellness Centre, joined me on this trip. She is very much in demand. As the Canadian Dr Thistle who works at Karanda full-time says of Karanda, ‘Pus Is Us’. Tania has been organizing all the donated dressings, developing simple protocols so nurses know how and when to use them, and teaching the nurses. She has also been adapting some of the wound-cleaning procedures. The staff at uniPharm, the wholesale company in Vancouver that supplies medications to various pharmacies throughout BC, generously donated many supplies such as eye patches, knee braces, etc. that were gratefully received.

Amidst all these challenges to provide the basics it does seem a little irrelevant to be maintaining computers and printers and training people to use software. However the staff continue to be gracious and hard working and receptive to change. Ray always emphasizes capacity building on these trips and that is our goal. I have more “help” from Ray’s team arriving this week to expand the training, which staff have identified they need. I anticipate a productive week.


It’s Been a Hard Day’s Night…Week

It’s Been A Hard Day’s Night……Week

Maybe we should have taken heed of the portents.

The weekly morning meeting started out with the news that the river would probably be completely dry by mid week and the bores were over taxed and could be tapped out by about the same time.

The work day started started with the chaos of the “head count”. Well let’s say the day to day tumult was added to by the head count. Someone somewhere in government (I was never truly able to ascertain whom), had determined that, on the busiest day of the week, every staff member at the hospital had to progress through several different desks and produce several different documents to prove they in fact existed and worked at the hospital. One staff member wryly observed that they wanted her birth certificate, passport, degree, licence to practice and her kindergarten report card. Ok the last bit was made up. It’s not that they didn’t actually have all this information already.

So while all the patients were making their now even slower progressions through their various queues , the staff were queuing up to prove they all existed. All this queueing was happening in the very  small corridor outside the administrative office where the photocopier was going overtime making copies of all this stuff.

Fortunately no-one cared if we counted or not.

On the very same day it had been determined (again I’m not sure by whom) that the floors in Maternity, Female Ward and the Family Health Clinic had to be resurfaced. The decree was that these areas needed to be closed and the patients moved out for the alleged three days it would take. Umm where? Certainly not to the corridor outside the admin office. So, amidst the chaos of the staff not being able to do their jobs because they needed to be tapped on the head, all the patients and hospital equipment had to be moved to somewhere. The female patients were squeezed (even further) into a section of the Male Ward and into the newly built Central  Sterilizing Room. Fortunately the sterilizing equipment had not been moved in yet. However, while there were basins in there for washing there was of course no toilet.

FCH was squeezed into a sweaty shoebox that was the patient Chapel, with the pregnant moms having to sit outside on a bench, inhaling the fumes of the solvent being used to prep the floors. The same fumes that caused the nurse to have an asthma attack and end up in Outpatients. Meanwhile the poor labourers were toiling away in the increasing heat. The move meant the nurses had no access to their computer (or the network) so we quickly had to rig a wireless piggyback to the room, dodging amongst the floor work in Female Ward (as that was where we had to position the extender) and then actually make some space so they could do their job.

On Wednesday there was a regularly scheduled visit from a Harare Orthopedic surgeon. In the middle of the working and operating day the power went out as per usual. More a hassle for them than for me across the hall trying to fix another computer. The complicating factor this time was that the generator quickly overheated from the load (the radiator was low on water) and shut down too. So everything (except for the computer system protected by the impressive back up battery array) ground to a halt until the generator could cool down and be restarted.

So, maybe we should have paused for a second and thought that, just maybe, the planets were not aligned for attempting  a major overnight upgrade of the computer software. However, the narrow window provided by the tick over into November (and therefore increased internet bandwidth) was at hand. I stayed up until midnight on Wed night in case I needed to be available to any prep work. The support staff in Canada let me go to bed while the download happened and then I got up at 4 to be on hand while the update progressed. All progressed reasonably fluently while most others were in bed but, as the sun and everyone else started to rise and started to get on the internet, the internet speed progressively degraded and made it  increasingly hard for the support team to do the necessary things via remote control. Increasingly we had to resort to them texting me with step-by-step instructions. I think you can imagine how tricky it would be to make sure cryptic command line instructions get relayed 100% accurately (is that meant to be a space there?), especially to a Mac user.

I didn’t share with the team back in Canada  that, all through this, the computers and the hospital had been running on back-up battery all night because the generator was having a rest from the toils of the previous day.

All too quickly the start of  the work day approached and then passed with the update still not completed. So I also had to run around to various departments telling people to not turn on the computers. Of course, in all the additional chaos on top of the usual tumult, just because you tell one person it did not mean the message got relayed to the next. So I had to go around more than once when we discovered folks trying to log in and thus interrupting the process. I then ticked  off more people by deliberately disconnecting them all from the internet so as to free up bandwidth.

Eventually the main update completed but all was not finished. It was then I discovered that each individual Virtual Machine had to be updated in order for them to “see” the update. Remember this is a Mac user trying to divine a path through the idiosyncrasies of Windows Networking and VMWare. So picture me banging away, swearing repeatedly under my breath (to be polite) while taking longer than was probably necessary because I didn’t really know what I was doing, to update each VM then saying to the receptionist “Go” every time I would get a machine done so she could call each department and let them know. All the while I was cognizant of the dozens of patients waiting in ever lengthening queues.

This already laborious process worked for those machines I could convince it to work on from the central console. There were just some that wouldn’t behave so, in addition, I had to run to various departments to physically assault, sorry update, the computer there.

All through this the staff and the patients were their pleasant, accommodating, unflappable selves. We never cease to be amazed by the locals’ ability to not be phased by all that is going on. Despite the massive interruption, everyone was still very kind and ridiculously grateful, sometimes for the smallest things (like the update enabling the chart number to be printed on the receipt!)  By the end of the (very long) day all the patients had been registered, seen, and attended to with the same minimum of fuss and not a single person expressed any hard feelings. Remarkable.

As of Friday the floors were still not finished………..

A special thanks needs to be said to the staff at Applied Informatics in Health Society ( which supports MOIS. For the last three weeks they have been graciously replying to the bombardment of emails I have been sending and then pulled out all stops to tweak the update to suit some specific Karanda requests as the Nov 1 deadline approached. They then worked many long, frustrating hours getting the update done over a very slow connection. An impressive feat given the time difference, distance and poor infrastructure. All of this for free as they have donated the software and their time to support this project in Karanda. Can’t express how important that is and how grateful the hospital and community are.

Nyanga Notes

Some thoughts and observations from Lori. The contrast between the airport in Dubai and the one in Harare was jarring. From the ultra-busy, aggressive name-brand consumerism, glitzty hub with slightly terrifying customs and immigration agent to the single-digit number of gates, random line-ups, and baggage handler/customs assistant who was eager to show us photos of his children on his cell phone.
I didn’t really know how I would react to Zimbabwe but I didn’t expect to experience the first-world guilt as a physical sensation; I find that my chest feels compressed and heavy. Yet people don’t want to be pitied. How can I transfer my sadness into a useful emotion? I feel helpless. Person after person standing at the side of the highway, some trying to sell produce or other goods while others are hitchhiking to somewhere. Regardless of economic status, people are dressed with care – no pajama pants worn in public here. I think the saddest part of extreme poverty is the waste of human potential. On the flight to Harare I watched the movie The Man Who Knew Infinity about the Indian mathematician Srinivasa Ramanujan who died in his 30s from TB but whose formulae are still in use today. It highlighted how genius is not dependent on culture or economic status (but life expectancy is).
I feel so naïve I don’t even know when I’m making a faux pas. When we asked our driver Tafadzwa about his family, he just said it was complicated. It was so awkward when one of the nurses we were introduced to suggested we could take her to Canada. Ditto our second driver. Everyone seems to be hoping that things will get better but then they will express pessimism at the likelihood of this happening. The ongoing emphasis on security is somewhat unnerving. Our first night in Harare we were on our own in a luxurious house and had locked up as instructed. The small dogs’ barking and howling woke us from a deep sleep and it was very difficult to go back to sleep afterwards. I’m glad I didn’t notice the baseball bats in each room until morning. At the cottage in Juliasdale near Nyanga we had the bizarre experience of wanting to go for a walk but being locked in our fenced yard and having to wait until the caretaker came by the house again. We haven’t felt unsafe, however.

We have seen a couple of lovely hotels but they have no visitors.
Our first driver graciously took us to the Lion Park near Harare our second day in the country. While it could be criticized for having animals in captivity, we were pleasantly surprised at the size of the lions’ enclosures and how healthy they looked. Too healthy for how close our car got to them during feeding time! The zebras, giraffes, and wild pigs also had a lot of room to roam. The attendants were knowledgeable. We have seen baboons and wildebeest in the wild.
The hospital at Nyanga is less busy than we expected. Basically there is not enough money for it to function or enough money for people to attend it. The pharmacy is heart-breaking – insulin has not been available for 6 months let alone any more mundane medication like hydrochlorothiazide for high blood pressure. HIV, TB, and anti-malarial medications are readily available as these meds are funded from organizations outside Zimbabwe. I am learning about first-line medication for all three conditions – never encountered in community pharmacy in BC because of central dispensing for the first two conditions and the rarity of the third.
But humour is ever present. People are consistently polite, kind, welcoming, smiling and often laughing (esp. when we try to speak Shona). We had a very funny moment today when Paul asked our driver what music he listens to and he started blasting Bryan Adams’ Summer of 69!