Sunday, October 25, 2015

Down the Back Stretch

One Last Week Ahead

I use the horse racing analogy not because of any fierce speed on my part; it is the time that is racing...  "Do not go gentle onto that good plane..."   or so said the non-guitar playing Dylan.   I am running as fast as I can to complete all I set out to do, but I fear I'll have a "DNF" posted.   This is probably how I feel every year. (And if I listened to what I tell my students, I'd go back and read my old blogs to see.)   Almost none of the uncompleted stuffs are related to needing more money. I realized a long time ago that I would never ever be able to give enough even with my small focus of the nursing school and St. Ann's -- things like the outdoor playground for the girls at St. Ann's.  The new basketball backboard is up and the girls really enjoy it and we have balls... However, it is really hard to change routine.  When I was at St. Ann's Thursday afternoon, it took over 30 minutes to find the key for the locked playground.   The girls had not used it since we left on Sunday. It is not that the sisters and matrons don't want them to play; it is not thought about, as it hasn't been done before .....  changing behaviours is slow work .....   I really would hate to see it sit locked for months .....  Dennis and I will be back to St. Ann's a few more times and keep kicking the can, but even if I stayed till Christmas some stuff would still not be changed .....  The good news is that if I get back next year, I will know where to start as the same problems may still be there!

Mental Health and Psychiatry

Last week the Graduate Academic Committee of the Graduate School of University Guyana approved the offering of the degree Master in Medicine, Psychiatry.    This was the last big hurdle before there will be an official Psychiatry Residency Programme in Guyana.   There is a more formal committee for the university but they almost always accept the working committee's recommendations.   A few of my colleagues deserve the credit for pushing this through - Drs. Bhiro Harry and Jorge Balseiro who did  all the research and document preparation for several long months.   It also had the support of the Dean of Health Science, Dr. Emanuel Cummings, and the Dean of the Medical School, Dr. Madan Rambaran, all of whose experience with University Committees were essential.   I had the privilege of attending the meeting as a "Visiting Expert"... I really think I was there to just add some colour.

Guyana is still number one in the world by population for suicides ..... and as you know if you read the papers online or even my blog, the events that scream the need for better mental health in the Guyanese community are the daily occurrences of spousal abuse, violence, etc.  There is now a concrete though long term approach to treating the most difficult mental illnesses.    Four general practice doctors will begin the three-year programme in the new year.    It is uncanny how one positive development can have the power to dispel the darkness.
This is probably from Confucius.   However, is also
the saying of a group from Maryknoll that I joined in 1964.  (Dennis as well.)
As much as I love psychiatrists and think they do wonderful things, I know that the new programme is only a tiny part of improving the mental health needs of the country and the delivery of services to the sufferers from mental illness.    There are other initiatives both by government and private groups, including faith groups.

Last Sunday, I was invited by the Youth Group of Holy Rosary to talk about suicide prevention and mental health.   Mental health needs are being brought to the forefront of public discussion over the last two years.    I am optimistic there are much better times coming in these areas.

More Mental Health

The new Minister of Public Health, Dr. George Norton, liked the idea of a National Mental Health Institute -- a separate place that would be the focal point for all Mental Health Services in Guyana, much like the Caribbean Heart Institute.  Recently, they have purchased two buildings near the hospital that will house the psychiatry outpatients, provide teaching classrooms for the residents' and medical students' rotations in psychiatry, a community reference library and meeting rooms, and the main office for the Mental Health Unit of the Ministry of Public Health.

Setting for the National Mental Health Institute (in progress)
on Quamina Street.

Leslyn Holder,
the new National Mental Health Coordinator.
We have a new National Mental Health Coordinator, Leslyn Holder, who is getting organized and presenting the first ever budget for Mental Health.  A costing accountant has detailed the costs of implementing the National Mental Health Action Plan 2015-2020.

Lots more good stuff is happening, including the third trip to Guyana of the Canadian Mental Health Team whom you an find on FB at:  Transforming Guyana's Mental Health System. Old timers Peter Kuhnert and Ram Kalap will be joined by first timers Lance Morgan and Shrenik Parekh.  They are here to finalize goals for the next 3 to 5 years.

Peter last year
Ram and John last year

Your Tablets and their Stories

The generosity of those who have little amazes me again and again.   When I was getting organized to come down, I had asked Elsie Asabere, the Director of the Nursing School if she could identify all the new first year students who had a device that could access the internet.   She wrote me back that there were only ten who did not have a tablet, laptop or phone; so I bought 20 tablets with donated funds.

However, when I got here there were 15 who did not have anything and a few more whose units were not really very good.   So I said that as I had planned to give five as photography contest winners to girls at St Ann's, could they decide among themselves which 15 students would get a tablet?  I was willing to just have two photo prizes if they needed more than the 15.   When I returned there were only 15 in total who needed a tablet ..... because, they told me,  the girls at St Ann's needed them more.  More?  I was amazed at their cooperation and generosity towards others.  

Well, I have run out of time to do the photo contest ..... so I decided to see which first year students really needed a tablet right now.  I knew two second year students had had their tablets from last year give up the ghost and they had no money to get another tablet ..... but the first year were my priority, so I asked who really needed a tablet.  (Some had little phones that could access the net, but I couldn't read them even with my glasses.  So I said that I had four extra ones now (I knew someone who really needed one in second year) and we would draw lots for who got them.      The next day I brought in some blank sheets to do the draw... And the class had decided that there were only really three students who needed the tablets and I could use the other for someone who needed it more.  More?

Another first year student came to tell me that a quiet student needed the last one... So I said, Fine send her in.   She arrived at my room and told me she had a phone but the charger was broken and was waiting for some family to come at Christmas to bring her a new charger ..... and in the meantime, she would use a batchmate's on class days.    She did not need it.   And she did know of one second year student who needed it more.  More?

I do not want them to sound like Mother Theresa - or else I couldn't yell at them when they gave a stupid answer (yes, I know there are no stupid questions, but there are some incredible answers) -- imagine yelling at Mother Theresa!   However, they are gracious, kind and generous... amazingly generous.   Next year, I will get everyone a good tablet - with your help of course...  I might even roll the donations to my beer fund into it as well.   I do know what more is...

The National Flower is Becoming Endangered

The government has banned the sale and use of styrofoam at the start of 2016.  The white food boxes have littered the landscape from ocean and canals to trees.   An amazing move!  And as usual, I have been ahead of my time:  I have been having my meals here in plastic reusable containers since Maria Kidner and Jane Greiling made me, back in 2003 (and as Kristin did many years ago in Dundas). Actually, they shamed me into it and -- and then they never came back to check .....   And today I have the same ones ..... though they have gotten stained over the years so the kitchen staff always ask me, "Have you cleaned these recently?"

Dennis is getting ready to leave the day before me, but not before packing his parachute and one more pink umbrella drink at Frenzy's Bar on a Saturday Morning...   He tells me that those umbrellas are nothing to laugh at as they are big chick magnets ..... Anyhow, the "chicks" get their laugh for the day....  All kidding aside, I will miss him.

Dennis will write next week's blog and I will probably finish up the following week.. Thanks for sharing our adventure - John, Dennis and Emilee.

Saturday, October 17, 2015

Back up to Speed... for Guys in their 70th Year

Veteran Dennis Arrived and Started Running [figuratively]

After some naptime (Dennis came by the redeye from Toronto), we headed down to St Ann's to look at the site for the basketball court Dennis and his friends planned to put up for the girls.   Many of the girls remember him; they were telling the "new" girls about the parachute though the new ones were wanting to jump out of a plane!   The yard has a good concrete base and with a little cleaning up will make great courts for basketball and volleyball.

Dennis is welcomed by all the girls - little and big- who remembered him.  Paulina at the Brazilian Churrascaria remembered his love of pink umbrellas.

Sticking with Basketball

We looked at several possibilities for putting up a backboard; these included stealing an old one from from the high school next door and getting a contractor-fabricator to install it on a pole embedded in the concrete so that it would be more permanent.  Sister Leonie had showed me the new one at St. Rosa's and it is a fortress..  and yes those are 12"Steel iBeams!  Not even in New York City!

Well, after  several weeks of me doing some ground work we had a contractor who knew all about building a basketball court - until I showed him a picture -- ugh.   However, he would get someone to call me back that afternoon ..... as you guessed, no call that afternoon, nor the next day, etc. .....  It is impossible to get anything done quickly in Guyana - or so I thought. 
On Tuesday afternoon, we went out looking for who had these basketball backboards and stuff... one sports store had a nice backboard and rim, but no attachment kit... not helpful, but they told us that any contractor could make one ..... probably the same one who never called us back.   We wanted something that was going to outlast the balls we had!  Permanence is more of a temporary concept in Guyana ..... We got our trusty taxi driver to take us to Gizmos and Gadgets where I had seen a portable one.  It was twice as expensive as just a backboard with no attachment kit and no fabricator to make one and not a chance that Dennis or I could weld one ..... The portable one looked great and was getting more sturdy-looking the more we considered our options.

A lovely sales person, Debra, came over and had heard our concerns about permanence and answered all our other questions.  We decided we would buy it.   Debra informed us that it would come in a box and unassembled ..... frightening nightmares of holiday-gift-assembling being done into the wee hours before the kids woke up... and now we would have 40 girls waiting for us to put it together.   
Dennis blinked first and asked if there was anyway they could assemble it ..... and yes, but there would be a charge.  He didn't even wait to find out how much... better option he said.     

Would they take Visa? Yes. Great. Debra returned with the bad news ..... They did not have any more, just the floor model.  Would they sell us the floor model?  (You know:  the already-assembled one. )  Debra checked with the manager and he said yes.   Now, could they deliver it?  Yes, but they would need to take it apart.  Debra saw the tears in Dennis' eyes ..... They wouldn't have to take it all apart! Joy again ..... And now the angel Debra says, "Maybe we can give you a reduction on the (already assembled and in perfect condition) floor model.. it was getting better ..... Yup, 10% off! 

"Delivery?"  "Yes, they would deliver it the next day ..... (Are you sure this is Guyana?) .....  and it is included in the price."   Now it was my turn to shed a tear, a helpless male before the beautiful youndg woman ..... "Do you think the delivery guys might be able to put it up?  Both of us went to school for too long and never learned anything practical."   (I offered to send testimonials from my children on my capacity to make two dozen trips to Canadian Tire for one leaky toilet repair ..... it might include a whole new toilet after it cracked for some unknown reason.)  Debra wasn't sure but she would ask the delivery man.  They held it for us and we returned the next day and paid and the unit got delivered the following day .....  

The two delivery guys met Dennis at St. Ann's (one of us had to teach, eh?), and they not only carried into the back of St Ann's where the playground is, but even filled the base with water to counterbalance the weight ..... especially in case Dennis was tempted to pull one of his from-the-foul-line Michael Jordan dunks.     He did help them by finding a funnel for the water and took some great pics .....  And they did all the extra, not because we were so persuasive but, as the  delivery man said, "This is for the girls at St. Ann's."

I sometimes pick on the "Just Now" time it takes to accomplish anything in Guyana; okay:  I do it all the time. So when I come on such an experience of great customer service and super-fast purchasing and delivery, I need to share these people with you...  So if you need something when you are in GT, go see Debra and tell her you are friends with Rev 1 and Rev 2.

Was it Worth it? You Tell Us...

Thank you, Dennis and his friends who funded this ..... You made the smiles happen.

And Even Better.. They Let the Boys Play

And please don't ask: modesty prevents me from disclosing who had the most baskets....

Way More Stories, But Enough

Lots of other stuff happened this week, so just look at the slide show...  and I'll mention a few really important ones next week ..... so stay tuned.   Amazingly, it will be my last one from Guyana this year ..... Dennis will do one after we get home.

So we went out to celebrate at the Everest Cricket Club,
where they remembered the Pink Umbrellas for Dennis.

Sunday, October 11, 2015

The Week After and The Week Before

Departures and Arrivals

Emilee Flynn has left and is back hard at work and Dennis LeBlanc is in the air going the wrong way from Boston to get here, but he said it was quicker.    So this week has lacked a little panache... Good but average... and for most of the week I forgot that I had my camera in my pocket... Must be my age or my biorhythms are off.   Anyhow, a colleague in Nova Scotia wrote me: "I guess the scary part is that neither Julie nor I found this last two weeks boring at all, even though this letter is about as mundane and ordinary as you can imagine. So either I am not much of a writer, or we are just getting more and more ordinary."   And I remembered a quote from Malcolm Muggeridge [1998:p 112] wrote, with much wisdom, that "the true wonder of life is indeed its ordinariness."   Sounds okay to me for a week, but I hope next week will be unordinary... at least a little.
Saying farewell and
Maggie looks happy?

Dennis will be joining me for the third time, so he is an old pro... And he has set out an ambitious agenda for the three weeks he is here.  I hope that I can keep up with him; I should, as he is older than I am.

 World Mental Health Day  

As you may remember, Guyana is Number One in the world in the number of suicides per 100,000; the WHO suggests that it is 44 per year.  The average in neighbouring countries is about 7 and in the world about 11.   So the Guyana numbers are really worrisome.   And to their credit the previous government and the present government have been trying to address the problem directly.    Today, the Ministry of Public Health hosted an awareness information session at the National Public Library (I may be wrong I think it is the only public library in Guyana. Yes or No?).
My friend Bhiro 
William Adu-Krow, Leslyn Holder,
Mosa Hudson, Morris Edwards

In typical Guyana fashion the 9:00 sharp start time became somewhere after 9:30 and the introductory greetings ran long, so the workshops were somewhat shortened.  However, this year's event was better attended than last.  I was talking about "Helping people who have suffered a loss by suicide".  I was actually quite busy with questions about almost everything in the Mental Health field other than the topic.    Actually, a medical student was there and we had a great conversation about coping with the special griefs surrounding a suicide.   She is a bright, young, engaging doctor and will be waiting for the Master in Psychiatry programme to get going at University Guyana, so she can begin her residency training.  And did I mention she thinks I am smart?  

The usual cast of characters filled out the speakers and presenters.   Bhiro Harry, Jorge Balseiro, Indhira Harry, Maria a Cuban psychiatrist, several psychologists, including Mosa Hutson who has been working now for over a year in Mental Health.   There were representatives from the Ministry of Public Health and William Adu-Krow, the head of PAHO in Guyana, and the Acting Chief Medical Officer Morris Edwards.    There is a National Coordinator of Mental Health, Leslyn Holder - a first for Guyana.  She is Guyanese and trained as an RN in England; she has returned to give something back to Guyana.   Her position is a vital step in the organization and growth of Mental Health Services.   I am starting to get tempted to believe that mental health services will improve and improve quickly .....  Mind you,  I have been wrong about married priests and just about everything else I have prophesied .....  But (just like the lottery ticket I just bought):  this one I have a good feeling about!

Leslyn Holder addressing the "Crowd".
Miss World Guyana was there with her entourage. She has
been dedicating her year to talk about youth suicide prevention. 

If you have read the following on FB you can stop.

Lunch with Kavita and Dolly

As I wrote on FB: I was honoured today by some old friends: Kavita Karran Sookhoo and her  husband Naresh, and Dolly (her mom) and the wonderful grandchild Kadesh. They celebrated a meal after church and it was the first time that they had a sit down meal since Kavita's father Kampta died several years ago. Dolly had made a special snapper meal; it was delicious.

I had to think for a while about what to get Kadesh to annoy his parents. A cricket bat, wicket and ball - just the answer as Kadesh started playing right away in the house. 

And as it is all over the world, especially since Robert Frost wrote a poem about it, there was  disagreement about where the fence should go.  It wasn't settled when I left...  It is somewhat comforting to know people are the same all over the world.

Have a good week, readers.  John

Friday, October 2, 2015

Emilee, my Guest Blogger

Stories by Dr. Emilee

 My niece, Emilee Flynn has spent the last three weeks in Guyana and most of her time here at Mercy with me.  I got to thinking -- I may have spent almost as much time with Emilee as I have with her mom, Monica, who was a lot younger than I was...and still is!  It was a great visit for me.  Emily writes:


For the last 13 years I have read my Uncle John’s “Ramblings.” I have read about his “other sons,” his girls at St. Ann’s, and the nursing students that he teaches. I have looked at the pictures that he has sent and posted and have marveled at their beauty. And I have waited for the last 13 years hoping for a chance that I might someday be able to join him and experience just some of the work that he and his many colleagues partake in. Well, my chance finally came and now it is my privilege to contribute to these “Ramblings.”

I am currently in the third and final year of my pediatrics residency at St. Christopher’s Hospital for Children in Philadelphia, PA. After much discussion, I received approval to travel to Guyana for three weeks as part of an elective in Global Health. I plan to practice in a global setting after residency and have applied to a number of different Global Health Fellowships and Programs. These three weeks have allowed me to at least get a glimpse of what I am signing up for in the future.

I was warned that it would be hot in Guyana. And yes it is hot, but I am adjusting. I was warned that there would be bugs and other critters, but that has never really bothered me. I was also told of the incredible kindness, hospitality and wonderful life-energy of the Guyanese people. And while people can tell you about that, such words can never fully express or do justice to the actual experience.
First time for Emilee and 28 years for Doc

Dr. Devi who is now Medical Director
and my doctor for Uncle John's bronchitis, now cured,
invited us over for dinner with some friends.

Dr Bhiro Harry invited us for dinner and his lovely wife Georgia
did all the work.  On the right is their daughter, Indira.

At my Taju's restaurant with the new
Mercy Corps volunteers.
During my first week I had the opportunity to see the work that Uncle John as well as many, many others have put into the Problem Based Learning Curriculum for the nursing students. I had the chance to sit in on some of their sessions and hear their thought process as they worked through the cases. I participated in some problem based learning sessions in medical school, but it was still a relatively new process when I was there. It was exciting to see how seriously the nursing students took the cases and began to direct their own learning and education. 

I was able to see one of Uncle John’s ethics classes in values and morality and then even helped to “grade” these papers after the session. In all fairness I warned Uncle John that I was an easy and generous grader before I started… pretty much the entire class scored a 15/15! And in true Uncle John form, I even taught one of the classes. I had only been in Guyana for 15 hours and he was already putting me to work! Fortunately he just wanted to give his students the chance to ask me questions and get to know a “young professional woman.” After so many years of reading his “Ramblings” I pretty much knew to expect something like this!

Dr. Rosa with Medical Students
I had the opportunity to discuss the medical care in Guyana with a number of different physicians my uncle has formed relationships with over the years.   My first experience was with Dr. Mallika Mootoo, a long standing Mercy paediatrician, who let me join her in two different clinics. (I will blame Uncle John for not getting a picture of us together.)
Dr Jabour

And through these conversations and experiences I witnessed the similarities as well as differences that exist between our health care systems. Parents are always going to have the same concerns, hopes, and dreams for their children and their futures regardless of where that child is living. It is a struggle both in Philadelphia and Guyana to help parents understand that children with asthma (or any chronic medical condition for that matter) need to take a medicine every day even though they may not be wheezing or having trouble breathing on that particular day. Parents still threaten their children that if they are not well behaved that they will get needles or shots, or “bored” as they refer to it in Guyana. This, by the way, is one of my biggest pet peeves as a pediatrician. It means that the child is going to associate going to the doctor with being bad and having to receive immunizations when in reality many visits have no immunizations.
Anyway ..… The hospitals in Guyana are promoting breastfeeding and keeping mother and child together in the same room. Both are AAP (American Academy of Pediatrics) recommendations and yet are initiatives that many US hospitals are still trying to promote and facilitate. There are relatively few subspecialists in Guyana, and the majority of care is provided by internists, family medicine physicians, and general pediatricians. There is no EEG machine (a test that helps to diagnosis specific types of seizure disorders) in Guyana as there is no one who has the training to interpret these test results. As I know my uncle has discussed in previous posts, there is still an incredibly negative stigma associated with mental illness in Guyana that has inhibited many from seeking appropriate care. And there are few training opportunities for providers to receive advanced or continuing psychiatric training or education.

One of the other reasons I came to Guyana was as part of the Bridges Medical Mission, a group of approximately 20 US based health care providers with skills in family medicine, pediatrics, Ob/Gyn, Cardiology, Urology, Dentistry, Nursing, Ultrasound Technician, and Respiratory Therapy. Many of the individuals in the group are originally from Guyana and some still have family living in the area. While some in the group assisted and provided direct care, many in the group worked on educational initiatives and helped to provide continuing medical education courses to local physicians and health care providers.

Guyana's population is approximately 800,000 with births of approximately 14,000 per year. According to the WHO statistics from 2012, the neonatal mortality rate (infants passing away in the first 28 days of life) in Guyana was 19.4 per 1,000 births. Compare this to other surrounding countries for the same year:
Trinidad and Tobago: 14.8/1,000
Surinam: 11.7/1,000
Jamaica: 10.6/1,000
Barbados: 9.5/1,000
Brazil: 9.2/1,000
Venezuela: 8.5/1,000
USA: 4.1/1,000
Canada: 3.5/1,000
Finland: 1.6/1,000

In terms of infant mortality (children passing away in the first year of life) Guyana ranks #65 in the world out of 224 countries.

As part of this medical mission I assisted one of the attending Neonatologists at St. Christopher’s Hospital for Children to teach Helping Babies Breathe Courses. Helping Babies Breathe is a neonatal resuscitation curriculum for resource-limited circumstances. It was developed on the premise that assessment at birth and simple newborn care are things that every baby deserves. The initial steps taught in Helping Babies Breathe can save lives and give a much better start to many babies who struggle to breathe at birth. The focus is to meet the needs of every baby born. Helping Babies Breathe emphasizes skilled attendants at birth, assessment of every baby, temperature support, stimulation to breathe, and assisted ventilation as needed, all within "The Golden Minute" after birth. The course is taught in a train-the-trainer model, thus allowing all those who participated in the course to take what they have learned and share their knowledge and skills with others in their communities.

The course is split over a two day period and utilizes role playing and simulation to work through scenarios that are meant to help participants recognize when a baby needs help making the initial transition into the world and taking their first breath. We conducted one course at Linden Hospital, which is about 2 hours from Georgetown. There were 7 midwives and birth attendants from Linden as well as the surrounding rural towns who participated in this course. We conducted a second course in Georgetown that was attended by 12 nurses and midwives including 3 nurses from Mercy Hospital. The other 9 nurses were from rural provinces and traveled 4+ hours for the course by taxi, boat, and bus. I was humbled by their willingness to share their experiences of delivering and caring for children in their rural and often resource-limited settings. It was inspiring to see the enthusiasm that many of these providers exhibited and their desire to share their knowledge with their respective communities while also continuing to seek out resources to further their own education and training.

Helping Babies Breathe is just one part of the Helping Babies Survive Program. Additional modules and courses focus on providing care for premature infants in resource-limited environments (Essential Care for Small Babies) and continuing to care for infants in the first 24 hours of life by encouraging breast feeding, ensuring that the child remains warm and dry to prevent hypothermia, continuing to monitor breathing, and providing appropriate vaccinations (Essential Care for Every Baby). Our ultimate hope is to return to Guyana within the next 6 months to provide these additional training modules to the same nurses and midwives that have just received training in Helping Babies Breathe. By identifying nurse and midwife leaders in each respective community and continuing to provide these identified leaders with additional education and training we hope to facilitate their own empowerment thus working from within towards the ultimate goal of decreasing neonatal mortality in Guyana.

And thus ends my “Ramblings.” Thank you for reading!  Dr. Emilee, Rev John's Niece

Stay tuned:  Dennis LeBlanc arrives in a week...