My Sister

My sister died of pneumonia today.  Who knows what was really going on.  All I knew was that she was sick.  Then she was at the hospital.  Then home.  Then the hospital again.

My sister.  A 34 year old Tanzanian woman.  Calling Memu my sister usually sets off eye rolls or exasperated comments from my friends.  I am not related by blood to Memu.  I have not even spent very much time together with this woman.

Maybe because of the intensity of the experience, arriving in Tanzania the day before my 21st birthday, traveling alone by myself for the first time, then managing to make a home for myself in another culture.  Maybe because the African sense of family is much broader, any woman of similar age to myself would be greeted as "my sister" in Tanzania.  Or maybe because of the intimacy of the conversations I had with this woman my sister.  For all these reasons and more, Memu became my sister.

Her boyfriend, an American, called and told me that she was sick again this week, and back in the hospital.  He had informed me the first time, which worried me, but my sister is strong.  I was not worried.  Hearing she was back in the hospital was concerning.

I met Memu in the fall of 2008.  I came to Tanzania to volunteer.  Her nephew, son of her oldest sister (Mama Gladness), ran a volunteer house where I was staying.  She would stop by to visit.  Eager to make friends with locals, I would greet her and ask her how her day was

I cook.  I feed the animals.  I wash the clothes.

I felt I had nothing in common with this woman.

A month into my stay, all the other volunteers left which was the best thing that ever happened to me.  I started spending more time at Memu's home which she shared with her mother.  I would watch her do chores, helping where I could, though I probably slowed her down more so than anything else.  Some of my best memories are in her kitchen, a shed attached to the cow pen.  With a pot propped above a small fire, the room would fill with smoke till I could barely see and my eyes watered as we chopped vegetables and talked about anything and everything.

English was difficult for my sister, but this did not deter her from asking me the most complex questions about America and the philosophy of life.  I was like a child.  She taught me how to carry water, to pick coffee, to cook like an African, and helped me learn to speak kiSwahili and kiMeru, the language of her tribe.

Every day I would finish volunteering and I could not wait to see my sister, tell her about my day and discuss differences between life in Tanzania and life in America.

My sister helps me with my suitcase

I learned that she was building a house in Maji ya Chai, water like tea.  In the month before I left, she took me to see the house.  Maji ya Chai is a small town between Arusha and Moshi.  While wazungu, or white people, have flooded into Arusha and surrounding suburbs for safari and volunteer work, Maji ya Chai was untouched by tourism.

We walked past shops and stands selling vegetables and began a long trek uphill.  We walked past empty fields of mahindi, corn and migomba, banana trees.  We walked across a small brown creek, for which Maji ya Chai received its name.  We walked through fields and past goats and past the water tower and finally as we seemed to near the end of civilization and I felt I could walk no further, there her house was at the top of the hill like a little oasis.

At the time Memu was living in the home of her mother; she had painstakingly saved money from selling the milk of her cow and piece by piece, bought land and built a house.  She had just finished the roof and had yet to add furniture and a few other finishing touches.

The only thing present in the house was a rug, so we laid out the rug on the floor, Memu bought sodas for us and we laid down on the mat drinking soda pop talking about boys and giggling like school girls.  It was one of the best days of my life, I can still remember pieces of that day so vividly, and fondly.

I came back in 2010, although my trip was cut dramatically shorter.  I stayed in her, now finished home, in Maji ya Chai for 3 weeks.  I almost didn't recognize it.  Fully furnished with a beautiful garden and even electricity, most prized of all was a water spigot in the back yard.  Even in Memu's mother's house, Memu would have to walk a half mile to the stream or to her friend's home that had a pump and carry water back every day in order to take care of animals, wash clothes, cook.  This home was a little piece of paradise that she had dreamed up and built up herself.

When I dream of Africa I dream of lying in her garden facing the sky and watching lizards and people pass by.  I dream of having a house on the hill in Maji ya Chai next to hers where I could visit often and laugh talk and learn.

I made the choice to stay and live in America and help people of my own country that do not have good access to health care.  I thought about coming back after classes were over, but I was busy with studying for the pharmacy boards and made the decision to wait until after my residency year.  I've been talking to my boss and making plans to come back in November.

Although I don't think that Memu would see these decisions as a failure on my part to be a true friend, let alone a true sister to her it has been difficult not to look back with regret if I had known! if I had known.  But I didn't know.  The Memu I know is a healthy woman, and stubborn to the point that even if she had hired help with her work, would probably do it herself anyway.  I felt so distanced from what was going on and so confident that she would get better.

I think of her fierce independence, her thought provoking questions in broken English, and her smile.  I think of her incredible patience with me and my complete lack of knowledge of Meru language and culture then her impatience watching her fiercely argue in Swahili to get the best deal on vegetables or bus fare.

It seems just too ironic that I decided to work with an underserved population in America then to hear that my sister died of pneumonia today.  No matter what the cause I know I would feel her loss but aside from that I cannot help but feel anger that her death today seemed to be so preventable.

In the end it didn't matter that she was well off by African standards.  That she had worked hard her entire life.  That despite not having a high school education I consider her one of the most intelligent persons I have ever met.  She died today because she was a woman living in Tanzania, without access to the same kinds of facilities medications and equipment that would be available in other countries.

People die preventable deaths in Africa everyday but Memu's strength had always made her seem untouchable to me.  I feel cliche writing this, I really don't know how to express what I feel.  If I just close my eyes everything will be alright.

She will be buried in her garden in Maji ya Chai on Tuesday.

Nakupenda dada yangu, I love you my sister.



http://www.youtube.com/watch?v=SyJzaPUbmEg

Genocide in the Age of Globalization

The road to hell is paved with good intentions.

It doesn't get more disheartening than that.

I've decided to use my coveted day off curled up on my sofa reading "The Blue Sweater" by Jacqueline Novogratz, about her experiences educating and lending to micro-finance groups in East Africa, focusing on Rwanda.  Its incredible trying to grasp just how interconnected the world is today.  I recently finished reading "Black Hawk Down" by Mark Bowden, which had nothing and everything to do with the 1994 events in Rwanda.

Black hawk down was a disaster and, with 20/20 hindsight, the book reviews where mistakes were made and where things could have gone better in the planning process, yet in the final chapter, the author reviews the events and despite setbacks, the Somalis took a higher toll during the mission than the rangers did.  Despite this, Clinton withdrew troops following the "failed" mission and the United States is no longer directly involved in Somalia.  Horrifying images of American soldiers' bodies being dishonored in the streets of Mogadishu appeared in the media.  With this fresh in the minds of politicians and the American public, there was a sense of reluctancy to involve ourselves in international affairs, especially those in Africa.

Only months later, on April 6, 1994 a plane carrying the Hutu president of Rwanda and president of Burundi back from peace talks in Arusha was shot down as it flew into Kigali, killing both men.  That night, the genocide began to unfold.  In 100 days, roughly 800,000 people were murdered by people whom may have been their neighbors, relatives, or coworkers.

To this day it seems that Rwanda serves as a guilty conscience upon the international community, especially the United States.  Because of the delay in labeling the conflict as "genocide" and delay in international involvement, thousands of people were slaughtered.

It is now eighteen years later and, unfortunately, its seems that history has a cruel way of repeating itself.  The United States is now working to finally withdraw troops from Afghanistan and have only recently officially "ended" our involvement in Iraq, after roughly a decade of heavy military presence in both countries.  Our reasons as a nation for entering each nation were very different.

My knowledge of Iraq and its history are fairly limited, but I can say confidently that Saddam Hussain was not a good man  and hundreds of his own people were killed under his watch.  Post 9/11 the Bush administration played to our sentiments and even Democrats authorized the start of a new war in yet another Middle Eastern country.  It took almost a decade before we officially withdrew troops and left;  Americans had long growth tired of hearing of our involvement in a country that had initially posed little threat to ours and there had been a growing opinion that we should not have entered to begin with.

Not all international interventions have been this disastrous; in comparison, our involvement in Libya seems to have gone relatively smoothly, although I am gauging this on the fact that our involvement was short-lived and that I have not seen much about Libya in the news recently.

Libya aside, my question is, when is it right for the United States to involve itself in the domestic conflicts of other nations?

More recently has been the plight of the Sudanese.  Sudan is (was) an astonishing large and diverse country.  The north has an Arab majority which the south is predominantly tribal.  In Julie Flint and Alex de Waals book "Darfur: a new history of a long war" the authors criticize the international community for labeling the conflict in this region "genocide" because, they argue, it is far more complex.  Although Omar al-Bashir was most certainly aware of, and likely supported, the Janjaweed's atrocities, tribal conflict as well as conflict with neighboring Chad contributed to the suffering of the innocent.  Again, the United States involvement was limited, if not non-existant, in this conflict.

In July 2011, South Sudan gained its independence (http://www.goss.org/).  Tensions in Darfur have calmed and people are finally returning home and trying to rebuild (Darfur is located in Sudan, not southern).  However there has been recent blasts from the media over a "new" conflict erupting in the Nuba mountains, just north of the South Sudan border.  Unlike the ruling power in Khartoum, the Nubians are tribal and are targeted by the government for ethnic and religious reasons.

Today George Clooney was arrested for protesting outside of the U.S. Embassy for Sudan following the release of a youtube video made by Clooney and the ENOUGH project on March 13 http://www.youtube.com/watch?feature=player_embedded&v=p89OuPODBMM.  Op-Ed reporter for the New York Times, Nicholas Kristof, has also written a number of recent pieces on conflict in this area.

In the final shot of the Clooney video, Clooney stands over a dead body decaying in the sand and words appear on the screen: How many more bodies until the Nuba Mountains become the next Darfur?

Do I care?  One-hundred percent.  I think that the world is too connected to allow these kinds of atrocities to take place unnoticed by the global community and, as an American, I believe that every person on earth deserves the basic rights of food, health-care and free speech.  However as the international community demands that Omar al-Bashir be overthrown and taken to international court for atrocities he committed, I can't help but think that if we did get involved, could this be another Iraq? Also, I think that there are more cultural complexities to the Sudan than even I can fathom, it may take more than removing Omar al-Bashir to establish peace.

The only thing I feel I know for certain is that I don't know what the solution would be.

CHEST 2012 is blowing my mind.

After committing the 2008 guidelines to heart and four years of reverence as my holy book, the time has come to toss out the old and move onto the new; CHEST 2012 is here.

Its absolutely amazing how much additional evidence has become available in four years and to see just how much has changed.  Although my work cut out for me, in reviewing the guidelines, it makes it easier to review what the experts recommend, rather than trying to go through all the trials and piece together recommendations myself.  When guidelines wait too long to provide updates, in the end, they end up discrediting themselves *cough* JNC7 *cough*

Less than a year out a pharmacy school, I still have trouble wrapping my head around some of these recommendations.  Have I become this set in my ways?

Let's look at CHEST.

Warfarin:
Warfarin can be initiated the same day that LMWH/fondaparinux/UFH is started for the treatment of VTE .  Pharmacy school hammered into my head the mantra "no loading dose, no loading dose, no loading dose" however new recommendations suggest that patients should be given 10mg of warfarin for the first two days, then dosing after that should be based off the change seen in the INR.  This recommendation seems to apply for any indication for warfarin start.  This will push the patient into range faster, examples given showed patients more likely to get to range a day ahead of patients dosed conventionally.

Rebuttal: First and foremost, I would have to review the individual trials to see if patients were dichotomized by age, but it is unclear if the guidelines are recommending 10mg for two days across the board, including our 80 year old grandmas.  I would like to see data specific to the elderly before following along.
Secondly, irregular dosing makes it more difficult to establish a starting weekly dose outpatient.  From my brief experiences in managing patients in an outpatient warfarin clinic, I have had the most difficulty dosing patients who received highly variable dosing in the hospital, which can end up meaning overshooting or undershooting their INR.

Despite this recommendation by the consensus guideline, I doubt that many of the anticoagulation pharmacists at my facility will buy into it.  The Navajo tend to be slower to respond to warfarin but much more sensitive.  For anticoagulation pharmacists across the Navajo Nation, it is hypothesized that there may be a gene that contributes to this, but we have no way of knowing which patients will be more likely to respond in certain ways.  Despite how slowly the INR budges in the first few days, some of the patients end up shooting up to incredibly high INRs in the second week.  Very little medical research is done on Native Americans (it doesn't take a rocket scientist to figure out why they may be adverse to the idea considering the history with white America) so again, I have no data to support this, but using a loading dose in this population may be more dangerous than using it in other populations.

Dabigatran.
Dabigatran 150mg twice daily is recommended over warfarin for patients with atrial fibrillation with a CHADS score of one or higher.

Dabigatran was approved for atrial fibrillation based off the results from the RE-LY trial, which only looked at 110mg twice daily or 150mg twice daily and excluded patients with a creatinine clearance less than 30mL/min.

I am so excited about the new anticoagulants, and if you understand warfarin, its not difficult to understand why.  Warfarin is a difficult drug.  But the fact of the matter is, these new drugs are relatively unknown.  It is difficult for me to consider recommending an expensive, new drug that has been studied limitedly over the gold standard of anti-coagulation that has been proven effective time and again in clinical trials.  Am I afraid of the unknown? To be honest, yes.  I know what to expect from warfarin, but I'm not entirely sure of all the risks I bestow on a patient by recommending dabigatran.

Furthermore, it is interesting that the guidelines specifically recommend only the 150mg twice daily dosing for patients with "good" renal function.  The 75mg twice daily dose was never studied in clinical trials and many of the new precautions with bleeding are specific to patients with impaired renal function, despite being on the lower dose.  A New Zealand study published in the New England Journal examined a series of case reports regarding bleeding with dabigatran showed that patients with low body weight, low renal function, and older age were at greater risk.  Furthermore, the makers of dabigatran recommend that the INR fall below 2.0 for patients previously on warfarin before starting, which may not always be adhered to.

"But dabigatran did not have that caveat; I think the government wanted it be used. They saw it as a good replacement forwarfarin and wanted as many people as possible to switch. The uptake was very quick—too quick. Doctors were very keen to prescribe it, and everyone got carried away."  Dr. Harper, the primary investigator, tells HeartWire (www.theheart.org).

To my knowledge, only two patients are taking dabigatran at my facility but are taking the 75mg twice daily dose (not according to my recommendation).  One of the patients was switched as a result of variable INR due to non-compliance.  This patient is not going to be anti-coagulated if she is non-compliant with her dabigatran, the difference is that we may not know the difference until she strokes out.

To summarize, I disagree with CHEST's "blanket-statement" recommendation and think that dabigatran should be recommended on a case-to-case basis and the greatest folly I see in the recommendation of the switch to dabigatran is to recommend it in patients who are non-compliant with warfarin.  Patients that refuse to take their anticoagulants will not be anti-coagulated.

Aspirin.
I have a couple of beefs with recommendations regarding aspirin in the new guidelines.

For patients that have undergone hip fracture surgery, there is a strong recommendation for clot prevention therapy for at least 10-14 days, out to 30 days.  Patients can use LMWH, UFH, fondaparinux, warfarin or... aspirin? really? aspirin?  It almost seems hypocritical especially because aspirin has not been recommended as sufficient clot prophylaxis in other scenarios.  LMWH is still recommended first line, and honestly I would need to see the full length VTE prophylaxis guideline to fully file my complaint on this one, but... really? aspirin?

Aspirin is recommended for anyone over the age of 50 WITHOUT symptomatic cardiovascular disease.  Aspirin is cheap and prevents clots.  In the early years of pharmacy school, I was told to give aspirin to anyone over the age of 50 AND to anyone with diabetes, regardless of age.  However, after presenting on the ADA/AHA/ACCF 2010 and U.S. Preventive Service Task Force 2009 guidelines, I began to change my mind.

The majority of trials looking at aspirin for primary prevention did not reach statistical significance additionally, practitioners are beginning to think twice about using aspirin because there absolutely is an increased risk of bleed associated with its use.  Both guidelines focus on weighing the risk of bleed against the risk of having an event.  The Task Forces break down the recommendation by age, and recommend aspirin for age cohorts based on the man's risk of CHD and the woman's risk of stroke. Check the document for the specific recommendation, but to ball-park it, use aspirin in patients ages 60-79 when man's risk of CHD is greater or equal to 10% or woman's risk of stroke is greater of equal to 10% (recommendation for use in patients ages 50-59 starts at a lower risk level ~5%).  The Task Forces do not make a specific recommendation for ages of either gender above the age of 80 due to significantly increased risk of bleed.

ADA is easier to follow but can only apply to patients with diabetes.  For men over 50 and women over 60 with an additional risk factor (smoking, hypertension, hyperlipidemia, family history premature CVD, or albuminuria) low dose aspirin is recommended.   Controlled risk factors are not counted.

The CHEST 2012 recommendation to use aspirin in any patient over 50 almost seems archaic in light of recommendations made recently by other major medical organizations.  The ADA and Task Force guidelines are fairly similar; the CHEST recommendation creates a major discrepancy among other major guidelines.

So

I may not agree with everything in the new guidelines, I may be wary to change my ways, but the great thing about the medical field is that is always changing.  A professor told me that she had been taught NEVER to use a beta-blocker in any patient with heart failure, now it is the standard of care.  These discoveries that completely change clinical practice occur on a year to year basis.  I think the best we can do is educate ourselves, read the literature, and keep an open mind.  Despite my complaints/rebuttals, I love my new CHEST which if filled with a plethora of fabulous recommendations and will help us to guide therapy to improve patient care.

References:
pending (please excuse my unprofessionalism), CHEST exec summary, Chest Anticoagulants, CHEST therapy for VTE disease, USPSTF 2009, ADA/AHA/ACCF 2010, http://www.theheart.org/article/1363757.do