News from Bolivia via Emily Moody (MP4)

Posted on behalf of Emily Moody, Medicine Pediatrics 4th Year Resident

Saludos desde Bolivia! I’ve been here two weeks, and it feels very familiar; even though it’s been 16 years since I lived in Santa Cruz (when I was a Rotary Youth Exchange student in high school).

The clinic here in Chilimarca was started about 30 years ago under the support of MAP, an international Christian health aid organization.  Jose Miguel deAngulo is the MD who came to run it in the mid-1980s (not sure exactly when). He and his wife Stella (who is a psychologist and program director) are Colombian, but moved here from the US where he studied public health at Johns Hopkins.  They raised their 5 children here at the clinic site, and home schooled them here.  The clinic is a primary care/urgent care clinic that provides basic vaccines, health visits, and has a basic pharmacy.

The scope of their work has changed over time. MAP initially supported a lot of outreach programs, including health promoter education for rural communities in addition to the functions of the clinic itself.  They had a very robust program educating “promotores de salud”, that reached many people. Initially it was 100% men from rural communities who participated in the program, but they ran into some problems with the men becoming very respected in the communities that some of them took advantage of their power and took advantage of young women in the communities (you will see the violence, machismo, and sexual violence themes return). So they started educating couples together, and also increased recruitment of women.  It took time for the communities to be willing to send women (they thought they were not able to learn the material, as women generally only completed a couple of years of school, and men completed a few years more), but it was very successful. In the last years of that program, they had 50% or greater participation of women.  They recently had to stop the program, because MAP re-organized priorities and was no longer able to support anything except the clinic itself.  In all, there are still >1500 rural health promoters in the surrounding communities that were trained here.

The women's group in Patamorochata in front of two houses: the white one was recently improved with plaster and cement as part of the Chagas control program, and the adobe one is how the house was previously.  On the far right is Stella Losada, the program director (and wife of Jose Miguel de Angulo, the local physician at the Chilimarca clinic)

Under MAP, they also started multiple other public health programs. One focused on increasing knowledge and community promotion to take care of children (also adults, but mainly children) with disabilities. It included some rehab, OT and PT some education on making and providing appropriate support devices, and a lot about education about differences. This was around 2000-2012, and this program has also been cut back by MAP.  It does still run, but is smaller.

They also have a Chagas program, for which they contract with the government to do Chagas screening.  The state program relies on people to come in to a clinic (in a city) to get tested, which is very unrealistic for a number of reasons. There is not a culture of primary care or well-checkups, so that is not an opportunity to do it. Many people from the rural communities believe that if you take somebody’s blood, then you have power over them to do witchery, so they will not make the trek to the city to give their blood – it would be ridiculous. So this program does outreach to rural communities. They do on-site education about Chagas, show what the vicuña bug looks like and how to repair holes in the walls to prevent them from living, and over time they establish trust to do the blood tests.  In a recent campaign in one rural community they had 14 positives. Those who screen positive then are referred to the central laboratory for confirmatory testing.  This program now has independent funding for the next three years.

The MAP clinic is still running. They have an 8am-10pm urgent care clinic run by nurses, 7 days a week. In the afternoon weekdays a general medical officer (MD from Bolivia, no residency) staffs a clinic also. They see anyone who comes through the door, with no charge.  They also have a dentist who works weekdays and a pharmacy on site with a well-stocked formulary.  Through the clinic they also do vaccines for children, as well as rabies vaccines for dogs.  Rabies is definitely here, in dogs and bats mainly. In Cochabamba last year, one nurse tells me they had >30 cases in people from dog bites.

The other large programs they run (sexual violence against children and infant mental health promotion and education) are entirely independent of MAP. Over the years of living in this community, they have come to see that there is a lot of violence inherent in society and specifically against women and children.  Within families and schools, children are hit regularly.  Sexual violence against women and children is also very common. Corruption within the police and courts is terrible, making it nearly impossible for victims of violence or sexual violence to seek justice.  The family (Jose Miguel and Stella) at this time are working to narrow their energies and focus their efforts on these two programs, because they feel that there are such deeply rooted societal problems that end up holding back children from developing their full potential, and that keep women from advocating for themselves and their children, that the other health projects don’t make the difference that they see can be made through their sexual violence and infant mental health work.

In Morochata with Dona Berta (the president of the local women's group and a health promoter) with
her 1 yo son Yoel and 9 yo daughter Sarah, and with Jenny, a lawyer who works in the rural communities as an advocate
for children and women who suffer sexual violence

As I mentioned earlier, Stella and Jose Miguel raised their family here. The kids were homeschooled here and enjoyed school and learning. The children’s friends from the community talked about the rote memorization and punishment that they suffered at school, and the kids were appalled – and one of the daughters made it her mission to start a school where other kids could enjoy learning as much as she did. They did it, and have a school for 6 mo to about 7 yr right next to the clinic.  It is a great place – they employ a lot of Montessori philosophy and have a garden and chickens, and do a lot of different kinds of hands-on learning. The school is also focused very much on involving parents, and providing a classes and instruction on child development and mental health – emphasizing attachment and security within the family.

With Daimar, a 4 yo with CP who receives services through the outreach programs for children with disabilities. 

One of the children in the family was then the victim of sexual violence. After she was able to tell her family, a long series of very difficult events followed that included trying to prosecute the perpetrator. They found that the society and judicial system are entirely set up (from mothers at home all the way to the courts) to blame the victim. Unequivocally. They struggled for a long time to get a lawyer who would actually advocate for them, and to get judges to hear the case. There were no resources available for the victim or family. So they started FUBE (Fundacion Una Brisa Esperanza) that advocates for victims of sexual violence. They have a building in central Cochabamba (Centro Una Brisa Eseperanza, or CUBE) where their activities are centered. They provide counseling services (they have 4 psychologists), legal services (4 lawyers), provide community and support for victims (who are ostracized by their communities after revealing the abuse), they do research, a lot of community education (to general public, police, judges, lawyers), they work for judicial reform.  They do a lot. The daughter who started this went to grad school for psychology and she and her husband went to law school, so they have part-time professorships at the Rutgers Law School and live half of the year here working for FUBE and half of the year in Philadelphia to teach, write grants, etc. They also do courses for US students to come here and learn about human rights law and judicial advocacy (for law students) and the health system (for nursing students). They currently do about 3 trips per year with 15-25 students (either law, nursing, or an interdisciplinary group) for 1-3 weeks each.

As I said, the main passion of Jose Miguel at this time is infant mental health. Between the machista culture, the violence, etc he sees that few babies establish secure attachment with parents from an early age. They focus on the first 1000 days (including gestation) as the most critical time for brain development and allowing the child to develop its full potential. They are planning to start programs including home visits, community education, and education within the schools.

For my clinical time, I have been working with Freddy (the clinic doc) to see patients together and do some pediatrics teaching. I’ve ordered a Harriet Lane in Spanish for them. I will also spend some time with the nurses in the urgent care when the clinic is closed.


The public health part of all of this is the most exciting to me. Since my area of public health experience is in environmental health, I’m working on developing a home safety checklist as well as a longer guide for home visits surrounding environmental health.  It has been fun, because the housing, city organization, and potential risks are quite different from those at home.  By the end of my time here, I also hope to have a presentation put together to do a sort of training or short course about environmental health.  I’m excited about the possibility that this will fit into and support the work they have already started.  Their model for the 5 main determinants of infant mental health include: physical development, socio-emotional development, cognitive development, development of auto agency, and safe and enriching environments.  My work will all be focused on that 5th determinant.

Hope reflects on the impact of visiting residents & medical students in Tanzania

Posted with permission from Medicine Global Health Chief, Hope Pogemiller

Habari ya Tumaini

(news from hope)

So, it’s been quite a while since I’ve written.  Life has become quite busy, and I have wanted to be thinking clearly before sitting down to write to everyone again. Today I realized I’m not sure I’m one to think clearly…linearly…  So, I’ll write a little on a more serious note.  Life seems so much more serious when you are freezing in the house with fuzzy socks and heavy sweater shawl in place and with a cup of tea.  (Yes, I know it’s 73 degrees. But, can you really put a number on “cold?”) As the content herein will be serious, I’ll attach a few pictures in a lighter vein. 

I’ve always quite liked sea slugs, and as it is the rainy season, slugs are abundant. One of my pastimes has become stalking slugs and taking pictures in the foliage.

F75 is a dog living near the canteen at Selian who was quite malnourished in January as she was breastfeeding her puppies. We named her after the initial formula fed to children with severe acute malnutrition—F75

In my short time in Arusha, I’ve been impressed with the lasting, positive impact made by the revolving door of residents and medical students at Selian and ALMC. They arrive with eyes wide open and energy. There is a general eagerness to help in addition to learn—many are surprised that they have plenty of knowledge to share with medical trainees.  The knowledge gained when visiting Selian and ALMC extends far beyond the sheer volume and serious medical acuity of patient interactions.  

I watch as people absorb the community-centered culture and are introduced to the medical system headed by a government who has a strong desire to provide affordable care to the vulnerable populations, as well as those in upper socioeconomic status.  This idealism is a laudable goal.  Lack of resources in necessary areas results in a medical system for the vulnerable that seems to limp along at times.  It can be discouraging operating within this context, with a serious lack of trained medical personnel in the country.  I think this is one realm in which international exchange with the many visiting medial personnel can be quite valuable.  

The influx of positive energy and new eyes analyzing dilemmas from clinical cases, to medical systems, to clinical education, promotes increased patient explanation from Tanzanians which spurs creative new ideas and approaches that help in the brainstorming process that can “fight the unbeatable foe.”   This truly helps to subdue that nagging feeling that your team is simply “rearranging deck chairs on the Titanic.”

 

One of the planes was owned by Wings of Hope previously… but I found the tail comforting ;)

View from one of my flights with the flying medical service to transport patients from the rural areas of Tanzania to a hospital. The pink dots are flamingos.

Another view from the plane

On a more personal note, friendships form quickly here, and many of them continue after resident/med student departures.  Likewise, it’s been very encouraging to find consultants in the US who are happy to help with tricky cases despite the lab and imaging limitations.  Forging friendships and professional relationships between hospitals in Tanzania and between specialists across countries is one path to a brighter future in the realm of medicine. 

One of my favorite people from New Zealand posing with me in the matching skirts we had made

My favorite New Zealand couple with me at a fabulous Ethiopian restaurant

I feel honored to work with so many Tanzanians and expats who are deeply devoted to medicine and the improvement of lives for individuals and the population as a whole.  It is not infrequent to feel incredibly inspired and unbearably frustrated simultaneously.  The roller coaster of life somehow seems more intense here than it might elsewhere.  As in any medical practice, some weeks are much more discouraging than others in terms of patient outcomes.  However, keeping a list of patients who left the hospital or clinic with a clear improvement in health has been invaluable.  As in the US, debriefing with hospital staff and families is cathartic for all parties involved.  

Closing picture of flamingos from a flying medical service to transport run

Megan Hilger's Reflections on Her Experience at Mulago

 Posted on behalf of Megan Hilgers, Pediatric 2nd Year Resident

Hello from Kampala, Uganda!

As my time here is nearing the end, I am thankful for the experiences I've had, relationships I've formed and vast amount of knowledge I've obtained. I spent my first week working on research in the hematology lab with Dr Troy Lund looking at markers of oxidative stress in G6PD deficiency. My remaining time was spent doing clinical work. 

Megan Hilgers with Derrick, the Hematology Lab Tech

Most of my clinical time was spent in the resuscitation room of the Acute Care Unit.  This unit is where the Pediatric ED, PICU and a transition ward are located.  I worked alongside the Ugandan residents, interns and medical students. As you would expect from the name, the patients brought into the resuscitation room are critically ill and require rapid interventions.  After patients are stabilized they are transferred to the PICU or ward where we continue to follow them with the team. The most frequent conditions we care for are sepsis, respiratory failure from pneumonia, severe acute malnutrition, hyperbilirubinemia and severe anemia. Oftentimes, these are in the setting of sickle cell anemia, TB, HIV or chronic malnutrition. Not only have I gained knowledge of these diseases and complications but I've improved my exam skills, procedure skills and even my ability to read blood smears. As a resident in the resuscitation room, I provided full spectrum care and I can now draw blood, place IVs, place I/O's, reconstitute and draw up meds, mix IV fluids and run a code with a lot more confidence.  I greatly enjoyed the mutual collaboration with the Ugandan residents as we discussed various patients and how management differs in the US. 

Ugandan residents with Megan Hilgers and a visiting Anesthesia resident from Stanford

Resources and healthcare staff are stretched thin in the hospital and posed many challenges that often fell to the parents/caregivers. Parents are relied on to monitor their child at bedside, administer medications, purchase certain medical supplies- such as blood culture bottles, pick up test results from the lab and even go to a nearby pharmacy to purchase inpatient medications when the unit is out of stock. Parents form a supporting community together within the unit and I often witnessed mothers teach each other how to express breast milk, use NG tubes, share meals with those in need and care for abandoned or orphaned children.

This is a great setting for residents interested in learning about management of critically ill patients in a hospital setting with limited resources.  There were a lot of opportunities for hands on management and teaching students and other residents.  It was very humbling and I cannot express strongly enough how grateful I am for this experience.

Observations from the Special Care Nursery at Mulago

Posted on behalf of Sarah McIntire, MedPeds 4th year resident

Eighty. That’s probably a good estimate of the average census in the Special Care Nursery at Mulago Hospital in Kampala, Uganda. On busy days, the number of infants can rise over 100. Clearly, there’s no such thing as a cap on the number of admissions we can take in one day, let alone a couple of hours. Here, the babies are divided into two rooms: preterm and term. Preterm infants can be anywhere from roughly 26-28 weeks (here, viability is typically considered 28 weeks), and often come in multiples – twins, triplets, even one set of quadruplets! Term infants can present with problems ranging from low Apgars at birth or respiratory distress, to asphyxia, seizures, or severe sepsis. As Mulago is a major referral center and a government run hospital, many infants are transferred in for complex management or simply because their parents cannot afford step-down nursery care at a private hospital.

The Special Care Nursery, where I work is quite different from the NICU I have become accustomed. There are no ventilators, only CPAP. There are very few continuous infusion pumps. Phototherapy is limited, and labs take about a day to turn around, so if an infant appears jaundiced, they are often just brought to a separate isolette and squeezed together under the lights. 

On my first day in the SCN, I felt overwhelmed by the sheer number of patients, and the limitation of resources. I could only think of what I wouldn’t give for a ventilator, or even just a quick CBC. At first, it was so hard to see past the differences between NICUs in the United States and here in Uganda. But, just like any new rotation back home, I waded right in, and started to realize that just because the care of newborns here is different, that doesn’t make it bad. It’s more about realizing how to make use of the tools you have available. 

Sarah and Kendahl with the Special Care Nursery Nurses

I learned to rely on mothers, who act as bedside nurses, and who don’t need a nursing degree to tell you that their child is too warm, or is breathing funny, or has a distended abdomen. I diagnosed a trachoesophageal fistula on my third day, after learning to place nasogastric tubes and having one that just wouldn’t go into the belly. Chest X-ray confirmed the TE fistula, and surgery was there the next day and ultimately took the child to the OR for repair. Just like back home (although perhaps without a CT scan or prenatal ultrasound).

But the most amazing thing to me about the Special Care Nursery goes beyond the medicine. My contribution of prescribing antibiotics or advancing feeds paled in comparison to the absolute love and devotion of the parents and families caring for these infants. I saw a mother, after breastfeeding her own child, pick up an abandoned infant awaiting placement, and, gently holding him, feed him formula from a syringe. She could have (and should have) been resting, but to her it was more important to care for this child who had been left behind. Another infant, whose mother died in child birth, was cared for lovingly not by his parents, or grandparents, but by his paternal aunt who gladly purchased formula to feed him, and stayed for days in the hospital until he was ready to discharge.

Special Care Nursery Nurses with Kendahl and Sarah

In a place where there can be so much tragedy (on reading the death log, it appears that about two or three infants die daily in SCN), it’s easy to feel disheartened. But on the eve of leaving, I can only say that I’m overwhelmed be the love and gratitude of the families and nursing staff here. It’s been an experience I’ve been lucky to have, and I look forward to more to come in the years ahead.

A final Asante from Ryan as he finishes his rotation in Tanzania

Posted on behalf of Ryan Fabrizius from March 6

 

Jambo from Arusha (actually waiting in Dar es Salaam airport at the moment)! 

 

Today marks the beginning of my journey back home. The past two months have so quickly passed, and this week has been a one of good byes and thank yous. I had the chance this week to do some home visits with the Hospice team. Unlike American Hospice care, the hospice team at Selian visits home-bound patients regardless of their life expectancy. For example, most of the patients that we saw have HIV infection as their primary debilitating illness, which, we hope, will not be life limiting if they are able to receive their medicines and routine HIV care regularly. The particular patients were selected because of their poor overall condition and lack of family support and resources. It was a wonderful chance to see a broader picture of the daily experience of these patients, seeing their homes, families, and neighborhoods. In health care, we life to think that the clinic appointments, hospital visits, and medicines prescribed make a big difference in someone's overall health, but seeing the patient's living conditions and imagining their daily life, I can see how far downstream we are from the roots of their problems. 

 

The last word in this series is actually one I have mentioned before, but it is so nice I'll use it twice. "Asante", as I have mentioned, means thank you. I have so much to be thankful for at the end of this two month experience. It has been a great joy to work alongside the Tanzanian medical staff at Selian, to experience their hardships, the challenges to caring for patients in this environment, and the camaraderie of sharing our knowledge, experiences, and goals. To let me follow along on their hospital and clinic rounds, my Tanzanian colleagues gave up their time and departed from their routine. But on top of that, I feel more than just a collegiality was fostered, that it was a lasting friendship. For that, I am thankful. Asante does not seem to explain this gratitude deep enough, but it is the best that I had to offer in return. Asante has been offered so many times during my stay here, both from me and to me. It is often for ordinary services, such as at a store or restaurant. It has been offered from our patients, often the most fervent "asante" coming from the patient and family for whom we have no good option to left. However, when I consider how much I have received during my time here, I wish I had more than just one word. I wish I had the power to help my friends accomplish their goals. I wish I could take the stories that I have seen and strike the problems at their roots. I wish we could all have equal opportunity to quality health care and the basic needs that would sustain that health. But for now, I offer thank you, and resolve myself to not forget what I have seen and the people I have shared life with here in Tanzania.

News from Laos and an U/S Project with Patricia & Junaid

Posted on behalf of Patricia Hickey (PL3) and Junaid Niazi (MP3)

Sabaidee from Laos!

Junaid and I are halfway through our rotation working with local Pediatric residents. Our role is to discuss patients with the residents and teach, as well as learn. These residents are completing 3-year residency programs developed by Health Frontiers, a group based out of the US. The residents are supervised on the wards by excellent Lao “teachers,” as they call attendings, and are also supported in their education by the Health Frontiers coordinator, currently a congenial Australian pediatrician. Visitors like us come from countries all over the world to contribute and learn. The Lao teachers are more patient with random foreigners coming to teach than I think we might be in the US. They trained at a time when resources were even more limited and the country was much more isolated from the rest of the global medical community but they are very competent and experienced. The mob of white coats on rounds is even more impressive here than at St. Paul Children’s as there are more trainees per team here. So there is plenty of teaching to go around...for the most part. This week it turns out most of the residents are attending seminars given by German Neonatologists so there is less for us to do. We can’t participate in patient care directly because we don’t speak Lao and don’t have Lao medical licenses.

Rounding

We arrive at the hospital in the morning after the residents have completed their morning report (in Lao) and most of their rounding. They are usually busy filling out fairly extensive paper charts and writing paper orders, which parents take to the pharmacy/radiology/etc to pay for each item of care ahead of time, be it an X-ray or antibiotic. The residents take turns presenting “interesting cases” to us - which as far as we are concerned is all of the cases. Even if it’s something we've typically seen, such as gastroenteritis, there are always discussions to be had about different management in areas with different epidemiology and different resources. Many of the cases have been especially interesting because they represent very late manifestations and advanced disease. There tends to be an additional element of mystery because of the frequent lack of diagnostic tools available. I think sometimes we have had the benefit of correlating history and physical more closely with diagnoses because of the extensive workups our patients have in the US. For example, here they may never know that a patient has Tetrology of Fallot because there is no Pediatric Cardiologist in the hospital and if the patient is too sick to be transported to radiology she won’t get an echo. There is a 6 month old baby here who I suspect has TOF but his last echocardiogram (performed by an adult Radiologist) months ago was read as large ASD which would not explain why he is in heart failure and has a palpable thrill.

The hospital

Resources here are changing frequently as Laos is a country in the midst of change. Construction surrounds us at every corner, from before dawn to well past sunset. We eat croissants for breakfast, walk to work dodging streams of shiny cars, and blend in with crowds of backpackers on our way to the hospital where there is minimal air-conditioning. Where you can be intubated but cannot obtain blood gases or portable chest X-rays. Where you can get a head CT but not an albuterol inhaler. Where we found a brand new ultrasound machine in the PICU untouched because no one was taught to use it. We have discussed the basics of bedside ultrasound with some of the residents and are working on a developing a “how to” guide, as well as planning several practice sessions. I am sure adoption of this technique will require much more reinforcement by people more qualified and more consistently present than we are but hopefully we have at least introduced the idea. This has the potential to be an incredibly valuable tool where portable imaging is not available and imaging in the Radiology department is not always affordable or attainable. We are grateful that we literally stumbled across this project and excited that several residents seem eager to learn bedside ultrasound. Before we leave Laos, we want to ensure that a procurement system is in place for ultrasound supplies—the gel, photo paper for printing images, etc. If we can accomplish this, then we will have given back a tiny fraction of what we have gained from this experience. Until next time!

Patricia & Junaid

Junaid Niazi, MP3 & Patrica Hickey, PL3

Pole - Swahili lessons from Ryan Fabrizius, MP4 in Tanzania

Posted on behalf of Ryan Fabrizius, Medicine Pediatrics Resident in Tanzania

Jambo from Arusha. 

Since last writing, I have been rounding on the medicine ward, which has been quite a different experience compared with pediatrics. While malnutrition and respiratory infections malign the infants and children, HIV devastates the adult population. Surprisingly, non-communicable diseases are just as common, if not more so, than HIV and its complications. Diabetes, hypertension, and chronic obstructive lung disease (emphysema) are much more common than I expected, and unfortunately, with the transition of local populations to urban lifestyles, will likely become the major burden of disease in developing countries like Tanzania. Just as it is in the US, chronic disease is difficult for patients to understand and providers to feel like they can make a difference, but I have been impressed by the knowledge and compassion of the local doctors to not just treat but to educate their patients on how to manage chronic diseases. For example, in outpatient clinic this week, I sat with Christopher, the internal medicine registrar, as he took about 30 minutes of a busy clinic day to explain diabetes type 2 to a patient. The concept of disease occurring without symptoms and not having a onetime solution is a difficult one to grasp, but Christopher patiently reached for common ground in understanding. Despite the myth that doctors in developing countries are "paternalistic", I have found that in this case and many others, doctors like Christopher strive to educate and empower patients and families to understand their condition and proactively participate in their own care.

For today's Swahili lesson, I wanted to introduce the word "pole". Just like "karibu", pole is a common and versatile word that enters into interaction several times per day. It is usually used here for "sorry", like when you bump into someone or walk on a clean floor with dirty shoes (I seem to leave a trail wherever I go). "Pole" also has some unique uses that we have observed. It is considerate to express "pole" when you see someone carrying a heavy load (we get a a lot of "pole"s when we carry groceries home up the hill). Many people will say "pole la kazi" when they see people at work, whether working at the hospital, harvesting roadside crops, constructing/digging, etc... It means, literally, sorry about the work. It feels similar to the feeling of sympathy medical residents give each other during a busy night shift or after a difficult series of events. To me, it seems to be expressing, "I have been there and I feel your struggle, hope you get to finish work and rest soon".

 

The most interesting use of "pole" for me has been with patients. When most local medical staff approach a patient on rounds or clinic, they usually begin with "pole bibi/babu/mama" (sorry grandma/grandpa/mother), which acknowledges the fact the patient is having a struggle. The usual response is "asante" (thank you), which feels like an expression of gratitude for recognizing the burden on the patient and family. As medical workers in the US, I think we do recognize the value of this sort of sympathy. Some useful expressions that I have learned from my teachers are "this seems like a difficult time for you" or "i'm sorry you have to go through this", but usually this comes up after a display of emotion from the patient or family that beckons validation. In clinical practice here, I find it most interesting that this validation and sympathy is the greeting, rather a phrase reserved for certain situations. It seems rooted in the community values here, that one person's burden is shared amongst others, not just friends and family, but all people that interact with them. Here in Tanzania, there are so many burdens that people carry, even in daily struggles for basic needs. It is frustrating for me, as someone that takes for granted that my daily needs are easily met, to see the barriers that people have to providing for themselves and their children. On top of that, the burden that HIV, chronic disease, and other medical conditions place on an already struggling people seem absolutely insurmountable. This, for me, stirs up feelings of injustice and unfairness, questions of why? and how?, and often results in frustration and fatalism. But for the people here, they bear with each other in these circumstances, supporting one another and carrying one another's burdens. Linguistically, I do not know if these words have a common root, but "pole pole" is another common expression that means "slowly" or "gradually". It is the unofficial mantra of climbing Mt. Kilimanjaro: gradually, one foot in front of the other. And such is seems with bearing one another's burdens. Sorry for your troubles, but slowly, together, we will carry it together.