Monday, November 5, 2012

Forewarned is Forearmed

Another Ultrasound Story from Roche Health Center
By Dr. Esther Kawira
Nyamusi Magatti helps with vital signs during clinic operations at Roche Health Center.

The patient was presumably 32 weeks into her first pregnancy. But when I examined her, the uterus was only the size of about 24 weeks.  The baby’s heartbeat was normal, however, so I knew she was indeed pregnant rather than having some other kind of tumor.
The usual cause for this, wrongly remembered dates, is easily determined by ultrasound.  Other common causes are late ovulation (which itself has several possible causes) or severe illness in the mother leading to undergrowth of the baby. This young mother appeared totally healthy.
I advised the patient to come for ultrasound, which she did a few days later, along with her interested young husband.
The cause of this problem was easy to see.  There was no (I mean zero) amniotic fluid.  The kidney areas of the baby were replaced by large cysts instead of functioning kidneys.  The baby was not making any urine, therefore the amniotic fluid, mostly made of fetal urine, was in this case not present, and therefore not cushioning the baby’s growing body.  The normally egg shaped fetal head was already flattened into an oblong oval by pressure from the uterine wall, and the fetal lungs, that normally are filled with fluid, could be seen to be “hypoplastic”, meaning underdeveloped.  Though the fetal heart was still beating, I knew that birth would be lethal to this baby, as it would not be able to even draw its first breath.
The husband peered intently over my shoulder at the ultrasound screen.  So I pointed out the head, and the beating heart, that are easily seen even to the untrained eye, even as my heart was sinking as I was putting  together the implications of what I was seeing. 
Knowing that these conditions can be genetic, I extended the scan to the kidneys of the mother.  I found that her left kidney was normal, but her right kidney was filled with about six large cysts. 
“Okay, I’m finished.  You can get up” I said to the mother.
When she and her husband were seated, I said, “There is a bad problem with the baby”.
Slowly I explained to them how a baby normally floats in fluid, how there was no fluid here because of a kidney problem, and how this led to a lung problem that would mean that either the baby would be born dead, or would die at birth.  I also explained that she might not go into labor at the usual time, because part of the trigger is the size of the uterus, and in this case the size would never reach that of a full term baby. 
Then I had to turn to the issue of genetics.  I didn’t know percentages, and anyway they would not have had much meaning for this couple.  So I simply explained that the mother also had cysts in one kidney, but that the other kidney was normal and could handle the job.  I said that the lethal condition of the baby might happen again, but they could also have normal children, just like the mother was normal. 
I wondered to myself later whether forewarning this couple of the lethal condition of the baby, and the possible recurrence, was a good thing.  But I concluded that “forewarned is forearmed”, and that preparing psychologically was better than the shock of giving birth to a malformed and lifeless baby when they were expecting a normal baby.  In this culture, where such things are often attributed to witchcraft, I got my scientific view into their heads first.  “ This condition is known and understood, we know what will happen at birth, and we have means to follow any subsequent pregnancy closely to either confirm recurrence or to be able to see a normal healthy baby.”

NOS 2011 Video featuring Michael Zaretsky and the Roche Health Center

This fabulous video captures the sights and sounds of the construction of Roche Health Center and features Michael Zaretsky reflecting on the history of the building. Enjoy!

Saturday, March 24, 2012

Do Mention It

Author: Dr. Esther Kawira
Medical Director for the Shirati Health Education and Development Foundation (SHED) and Roche Health Center.

Do Mention It

There are some things the doctor would like to assume the patient would mention up front. For instance:

"I am pregnant". Or,

"I was already diagnosed with HIV and I am taking ARV drugs".

If these things come out late in the consultation, they change everything.

A few months ago, I received a young woman with her sick child, a girl of about 10 months of age. The child had been sick with a cough and fever, plus some weight loss and constant fretfulness. The mother told me up front that she herself had HIV, and was taking ARV drugs. To me, the mother appeared to be doing well, and looked healthy.

My fear for the child was allayed when she tested negative for HIV. I put the child on antibiotics for pneumonia. When I saw her again a week later, she was no better. In fact, her weight had shrunk by another kilo. The child looked emaciated and weak, and was still coughing and febrile. I started thinking of TB.

When an infant or child has TB, the doctor should always look for the sick adult in their environment who infected them. So I asked the mother if anyone at home had been coughing also, or had been treated for TB.

"Oh yes", she responded, "I had TB, but I took drugs and now I am better". With further questioning about the time frame, it became obvious that the mother had infected her infant daughter before starting TB treatment herself. The child was now suffering from this treatable and curable condition.

That very day the child started the TB drug. One week later, she was no longer having fever, her fretfulness had gone away, and she was sleeping soundly at night. Over the succeeding weeks her cough went away, and she started gaining weight. Now about four months into the six month treatment, she looks and acts like a healthy one year old. The young mother, also doing well on ARV drugs, will likely survive to raise this child to adulthood.

Information about the author: Dr. Esther Kawira, Medical Director and founding member of the SHED Foundation, is a Diplomat of the American Board of Family Medicine and has a faculty appointment at the University of Southern California, School of Medicine (USC). She has worked in the Shirati region of Tanzania for over 20 years.

Tuesday, March 20, 2012

The Newest Village Life Outreach Project Committee

2012 is passing quickly, but Village Life Outreach Project’s fourth, and newest, committee isn’t letting that time slip away. After years of leadership by UC DAAP professor Michael Zaretsky, and significant accomplishments documented throughout this blog, it became clear that the work of the Roche Health Center is only part of a number of long term goals set by VLOP leadership. Based on this realization, the Building Committee was formed in January of this year. The committee will be responsible for all built works undertaken by VLOP, including research, architecture, construction, and evaluation.

Goals for 2012 include the design and construction of medical personnel housing that will allow the health center to provide medical care in this remote region a minimum of five days a week (it is currently operational twice a week), and construction of a new primary school in the village of Burere, designed and built in partnership with the University of Cincinnati Chapter of Engineers Without Borders ( These two projects are led by subcommittee chairs Michael Zaretsky (Roche Health Center) and Tom Bible (Burere School), and maintain VLOP’s goals of social and environmental sustainability. Additional projects include a rainwater catchment system, ISSB research, continued evaluation of the Roche Health Center, and participation in the discourse of public interest design.

Village Life is committed to enriching the experiences of individuals and communities, both in Tanzania, and here in Cincinnati. The lessons learned through travel to unfamiliar places and working with communities in villages such as Roche, provides opportunities to grow both personally and professionally. We are excited that many students and professionals have participated in the Building Committee over the last three months, and are looking for ways to continue to involve the community. If you, or your firm, are interested in getting involved, the committee meets every second Monday of the month at 6:30 PM in Coffee Emporium’s Over the Rhine location (110 E. Central Parkway. Cincinnati, OH) or contact Village Life at

Look for more blog posts – including images of our designs as they progress - coming soon!