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Know Your Specialist

Dr Julio C Gonzalez Gutierrez speaks on pre and post Operation anesthesia care

The MidweekSun Admin



Dr Julio C Gonzalez Gutierrez, Consultant Anesthesiologist and Medical Director of Trustanaesthesia Services (Pty) Ltd. affiliated with Bokamoso Private Hospital talks to SunHealth about the continuous medical care anesthesiologists provide before, during and after an operation to permit the surgeons to perform surgeries.

Despite being an integral part of modern surgery, most people know very little about the process that sends them to sleep before their operation. Explain to us what anesthesia is? What happens to the patient? Is it literally like going to dreamland or it’s a total blackout?
Good question: Anesthesia is combination of unconsciousness, muscle relaxation and pain free status. A person can be under general anesthesia for many hours, as long as the anesthesia is conducted by a properly qualified and well-experienced Anesthesiologist. For the patient it is like a total blackout yes.

What type of education did you have to pursue to become an anesthesiologist? And why did you decide to become one?
Anesthesiologist are Medical Doctors (6 years) first and then after concluding the post-graduate or community service they officially begin training in Anesthesiology specialty (4 year) of which concludes with board examinations and certification or equivalent. The duration of study is 10 years. It is after all this time that the real experience begins. In my case particularly, I decided to become a Doctor because I love and wanted to be that Doctor that keeps patient alive and safe during surgical procedure and that Doctor is the anesthesiologist.

What services does your practice offer?
We at “Trustanaesthesia Services” are involved in the preoperative period of the patient meaning (before/during and after the procedure). We play a pivotal role in the critically ill patient at the intensive care unit in particular, and provide chronic pain management service to selected patients. An anesthesiologist also plays a role in a hospital or clinic emergency room and in the MRI/Tomography room as well for selected patients as well.

What do your daily duties entail as an anesthesiologist?
Well our duties start the day or few days before surgery by consulting/examining and reviewing the patient. We look at conditions, Laboratory results, Radiological films and optimizing treatment if necessary, all this geared to tailor make the anesthetic plan for the particular patient and surgery that can yield the best results. No patient should be anesthetized without first being seen by the anesthesiologist to be able to evaluate the risk and possible complications during and after the procedure. A person’s life depends on that during the operation. Anesthesia is one of the safest specialties in medicine but usually direct anesthesia complications are lethal.

A typical day for you would be… ?
As explained before, we do clinical work during the procedure and also office work preparing or planning for the surgeries the following day. We also drink lots of coffee.
One little-known fact about anesthesiology is…
We are safety advocates in the OR suite.

I have read that patients who snore and those who are obese tend to be the most problematic when they are put under. Why is that?That is very true. Obesity brings a huge risk for the patients due to their massive size; everything becomes much more difficult to attain. To secure airways is extremely challenging because standard instruments are designed for normal size people and their cardio-respiratory reserves are limited. Obese patients are challenging from the pharmacology point of view due to their large surface area and concomitant diseases associated to obesity and last but not least in the recovery period, obese patients are at higher risk of respiratory complications compared to normal size patients. The anesthesia for these types of patients is always modified and very challenging.

There are cases where some patients wake up too early or worse never wake up at all. What would have happened?Well to answer this question we need to look at the history of anesthesia many years ago. Yes in those years lack of adequate instruments, lack of monitoring, un-purified drugs and poor training made anesthesia sometimes dangerous but today we can monitor everything during the course of anesthesia and detect anomalies early enough before the complication is evident. Training is more standardized and practices thrive for clean safety records. Nonetheless in emergency situation that cannot wait the risk of poor outcome is much higher.

Also the type of patients sometimes make surgery very risky; for example: a 90-year old patient that had MI last month and is known to suffer from renal failure now presented with stroke and acute appendicitis that needs to be operated – the risk is very high for complication from surgery and anesthesia during the peri-operative period. Now if a patient wakes up and awareness is detected during the anesthesia, probably the anesthetic gases would have run out and the patient became slightly conscious (situation that is easy to correct) without a bad outcome for the patient. Dying on the table is rare these days unless the surgery is done on high risk patients under emergency circumstances.

What do you say to people who fear being put under? Is that fear justified? Not at all, not in today’s modern Anesthesia. I would recommend seeing a consultant anesthesiologist before the surgery and rest assured she or he will put the patient’s mind at ease before the surgery and anasesthesia. I particularly don’t like to anesthetize frightened patients except where critical.

What are the tools of the trade that you use the most? Anesthetic machine, Laryngoscope, syringes and medications especially designed for the anesthesiologist to use but the most used tool of the trade is your ability to think and take corrective decisions under pressure. In this case your tools are your brain and training.

Does it bother you that despite the critical role anestheologists play in the operating room, they hardly ever get any recognition?That is very true especially in the modern medicine, but it doesn’t bother us because we know who have the patient’s life literally in their hands. We also know our involvement is brief but intense; we don’t expect you to remember us.

Why do you think there are so few anestheologists in the country?
Well, not only in the country but also in the whole world there are a few qualified anesthesiologist. I think it is possible that all the things mentioned earlier and the stress and pressure of the specialty have a role to play in the numbers. Here in Botswana anesthesiologist services are poorly recognized and hence poorly remunerated unlike in developed countries. In industrialized countries anesthesiologists are some of the highest paid specialists.

What do you find the most rewarding about the work you do?
Knowing that your prompt and effective interventions help safe patients. It is also in the way we make extremely complicated surgeriespossible.

And the challenges?
Time management and trying to convince your colleagues that your thinking in outcomes is not in the technicalities of the procedures.

On a basic level, what skills does your job demand?
Vast knowledge of how the body works (Physiology); vast knowledge of the disease of the patient (Pathophysiology); and vast knowledge of how medications work at cellular level. Anesthesia is a procedure-oriented specialty like the surgery; that is why they are intricately related – and last but not the least, it needs a cool and calm head under stress or pressure.

How is the job market/demand in the anesthesiologist field? How do you think it will develop over the next five years?
The market is ever growing and so are the demands for anesthesiologists in Botswana and the world over. New surgeries and techniques with better and safer instrumentation are being developed but at the end anesthesia has to be given by a human being, not by a machine.

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Know Your Specialist

Dr. Emily Shava explains the Antibody-Mediated Prevention (AMP) study

DR Emily Shav



Enrolment is ongoing in the Antibody-Mediated Prevention (AMP) study. Tell us about that. What is AMP and how exactly does it work?

AMP is a multicentre study being conducted in different countries by two global networks known as HIV Prevention Trials Network (HPTN) and HIV Vaccine Trials Network (HVTN). The AMP study in Sub-Saharan Africa is enrolling women and is also known as HVTN 703/HPTN081 Study. Women because in Africa they are among those at highest risk of HIV infection because of their physiology and gender based imbalances. In this study broadly neutralising antibodies (Bnabs) known as VRC 01 are being studied to see to what extent they can prevent acquisition of HIV-1(efficacy) and to what extend VRC01 can be tolerated by participants (safety).

This is a follow up of previous studies which showed that VRC01 is generally safe and well tolerated (HVTN 104).
It is a double blind randomised placebo controlled trial. This means that participants do not choose which group they are to be on. The study has 3 groups, high dose VRC01, low dose VRC01 and a placebo group. They will NOT know which group they are in and the clinicians consulting them will also not know which group the participants are in. Only the site pharmacy personnel are unblended – they know which product is which. This is important to prevent bias. BHP has engaged and continues to engage various stakeholders (including Ministry of Health and Wellness, DHMT, clinics) and communities through the BHP community advisory board since 2015 when we were selected to take part in this important study. The success we are talking about now would not have been possible had the different stakeholders and communities not been on board.

What is your role in the Study?
I am the study coordinator for the project, responsible for day to day running of the study clinic. The person with overall responsible for the study in Botswana is the site investigator, Dr Joseph Makhema.

Who are the participants in the study? How many people are required and how many have you enrolled so far?
The participants are healthy HIV negative women at risk of acquiring HIV, aged between 18 and 40 years and willing to take part in the study. They should not be pregnant or breastfeeding and should be willing to use effective contraception to prevent pregnancy since the effect of VRC01 on pregnancy is unknown. In Sub-Saharan Africa a total of 1900 participants will be enrolled from Botswana, Kenya, Malawi, Mozambique, South Africa, Tanzania and Zimbabwe. 1555 participants have been enrolled as of the end of April. From Botswana a total of 150 participants will be enrolled.In Botswana the AMP study was activated in July, 2016. The first participant was enrolled on August 16, 2016. To date 236 participants have been screened/checked for eligibility to participate in the study and from these, 122 women have been enrolled and are on study as of May 4, 2018.

Willing participants provide written informed consent after discussion of all procedures, and their risks. The informed consent forms together with the protocol (document that explains how the study is conducted) and other pertinent documents for study conduct are submitted for approval by the Ministry of Health and Wellness, Institutional Review Board (IRB) known as Health Research and Development Committee (HRDC). This is the committee responsible for approval of research conducted in country.

What are the fundamental questions about HIV prevention that the AMP Study is designed to answer?
Are people able to “tolerate” the antibody without becoming too uncomfortable? Does the antibody lower people’s chances of getting infected with HIV? If the antibody does lower people’s chances of getting infected with HIV, how much of it is needed to provide protection from HIV?
When did it begin and when is it expected to end?
In Botswana the study started in July 2016.Total duration of study is 5 years. Each participant stays on study for about two years.

What HIV preventive care do volunteers receive and how are you ensuring the safety of study participants?
Participants come for study visits monthly. During these visits, we do what is called “history taking” from the participants to find out how they are feeling and have been feeling. We examine them and we conduct laboratory tests to ensure safety. To prevent HIV infection, we provide risk reduction counselling and HIV prevention package per Botswana Standard of care

What impact will this study have in the future of HIV prevention?
We generally liken HIV prevention options to a tool box. We currently have various behavioural modification options in this tool box, including abstinence, use of condoms effectively and consistently. It is therefore important to also add more biomedical interventions in this tool box. bNabs would then be an important addition if proven to be effective. This would lead to more combination prevention options. The idea of a toolbox with more tools in it is important because we know that when people have more choices, it increases the chances that an individual will find one tool that fits their needs and circumstances. Those decisions can be influenced by many factors – cost, ease of use, availability/easy access, partner agrees to use, etc. –so having more tools will mean increasing the chance of serving more people’s needs for HIV prevention.

How will the findings benefit Batswana?
I would say that it is too soon to say what direct benefit there may be to Batswana. This trial is about proving the concept that bNabs can prevent HIV. More trials will be needed to find the best antibody, or combination of antibodies, how to best administer them as a public health strategy amongst other things.

We know the strides science has made in the war against HIV/AIDS. There are very effective drugs and that is great news. But what do you say to young people that would say to you that it’s no big deal to get HIV and that there are already good drugs to control the disease as if it’s diabetes?
Prevention is ALWAYS better than cure. We are truly grateful for the strides that have been made in science to avail great treatments for HIV treatment. We do not yet have all the answers about the various great treatments available, time generally brings things to light. Additionally, prevention is more cost effective than treatment or a cure. (Note that in the question, diabetes isn’t cured – it is treated as a chronic illness.) That is important to individuals, and to countries/public health systems.

From your experience, do you believe that there will be an effective vaccine and/or cure for HIV in our lifetime? Is that an achievable objective you think?
Please note that in AMP study, the study agent VRC01 is NOT a vaccine but broadly neutralising antibodies (bNabs). This study could help us develop a safe and effective HIV vaccine more quickly. An HIV vaccine developed more quickly because of this study could essentially teach the body to make antibodies like VRC01 (without getting the VRC01-like antibody through an IV/drip). To develop a vaccine like that we need to understand more about how VRC01 may work, and how much is needed to “work” (to prevent HIV infection). This study should help us learn that. My answer on vaccine in our lifetime would be YES. The Thai Trial, RV144, showed us a vaccine regimen could reduce new infections by about 32%. That wasn’t strong enough to license, but it paved the way for a great deal of additional research. There are 2 efficacy trials currently underway in sub-Saharan Africa testing different vaccine strategies (one of which builds on the Thai results), so we have come farther than ever before.There are various international organisations with scientists whose main focus is the development of the HIV vaccine such as the HVTN, International AIDS Vaccine Initiative(IAVI) etc.

I understand that the HI virus lives not in the blood but lymph nodes and some organs. Is there any research
currently being done to try and flush out HIV from these compartments so that it can be killed by the antiretroviral drugs?
To clarify, when a person is on antiretroviral therapy, the amount of virus also known as viral load in blood will reduce. Generally, if a person is not on treatment the viral load will remain high. For people on treatment with low/undetectable viral load, scientists are looking into ways of flushing out HIV from its hiding places like the lymph nodes termed the “shock and kill” strategy.Currently I am not aware of any such study being conducted in Botswana.

HIV was around for decades before it was discovered and diagnosable and infecting humans during that period. Has anything been learnt from that to prevent a recurrence with another type of retrovirus?
This is a difficult question, yes human beings are capable of learning to better themselves in the future, to what extent, time will tell.

What good news can you give readers of this interview who are living with HIV/AIDS?
If someone knows they are living with HIV, it means they have been responsible enough to take the test and know their status. This needs to be commended. Currently we have available in this country potent antiretroviral treatment with minimal side effects, which means that people living with HIV can have improved quality of life, including sexual reproductive health and live longer.
I would also like to take the opportunity to highlight the importance of universal test and treat and for all HIV infected people to be on treatment and to take the treatment diligently. This is important because a persistently undetectable virus is not transmissible.

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Know Your Specialist

‘Merck More Than a Mother’campaign coming to Botswana in 2019

Dr Rashakelej



Pharmacist and CEO of Merck Foundation Dr RashaKelej, has made it her mission to raise awareness about the discrimination, stigma and ostracism women undergo for their inability to have a child. Here she discusses with SunHealth how her foundation is empowering women across Africa and other developing countries.

Dr Rasha Kelej, you are CEO of Merck Foundation, can you start by introducing the Foundation for us?

Merck Foundation is the philanthropic arm of Merck KGaA Germany. It is non-profit organisation that aims to improve health and wellbeing of people and advance their lives through science and technology. Our efforts are primarily focussed on raising awareness about non-communicable diseases, empowering women and youth, improving access to innovative healthcare solutions in under-served communities, building healthcare and scientific research capacity in the fields of diabetes, hypertension, cancer and fertility care in underserved communities. Our vision is to see a world where everyone can lead a healthy and fulfilling life.

You will be launching the ‘Merck More Than a Mother’ campaign in Botswana in 2019. Can you discuss when this launch is expected to happen and what it will entail?

We will launch in Botswana sometimes in the first quarter of 2019 in partnership with Her Excellency First Lady of Botswana Madam H.E. NEO JANE MASISI, and ministry of health of Botswana. We will first launch the Merck more than a Mother campaign with Her Excellency as the Ambassador with the aim to empower infertile women through information, health and change of mindset.
As part of the campaign we will call for application for media recognition award of Merck more than a Mother. And we will also train media about health reporting and sensitive issues reporting such as infertility. We will also launch the start of producing a song about infertility stigma and sensitising the community to break its stigma.

In addition to providing training to doctors in the fields of fertility care and oncology we will also launch a pilot project called blue points where we will provide one year diabetes diploma to doctors to build Health care capacity in the country. Our vision is to develop a strong platform of specialised doctors to improve access to quality and equatable healthcare solutions in Botswana.

When did this campaign start?What makes “Merck more than a mother” such a unique campaign and how do you hope it will be embraced by relevant stakeholders?

We started Merck more than a mother campaign in 2015 first in Kenya then Uganda and the rest of 35 countries in Africa and Asia.The campaign is an exponential success, the ambassadors of Merck more than a mother, The First Ladies of many countries, are very active and increasing every year. We have partnered with ministries of health and academia of many countries who are working closely with us.

The social media followers and videos viewers are in millions. Merck Foundation has trained more than 100 fertility specialists over the last two years in more than 30 countries in Africa and Asia. Thousands of women are sharing their stories of suffering  every day; African media has started to discuss the issue every day, and we also worked with singers to write songs and produce video clips about infertility and delivering the message to all communities, since in many cultures infertile women suffer discrimination, mistreatment and physical and psychological violence. We have also supported the establishment of first ever Public IVF centres in Rwanda, Ethiopia and Uganda.

The Foundation seems to be so fond of Africa why the interest, many will ask? How do you settle on the choice of health needs or area and the countries that you engage with in Africa?

Prof Frank Stangenberg Haverkamp, the Chairperson of E-Merck KG and Merck foundation is very fond of Africa and believes in its potentiality.  Furthermore, there are many challenges in Africa with regards to healthcare and this is our speciality we can help, and this is what we do and we do it well. But we also focus on Asia, we have programmes in many countries such as Sri Lanka, Bangladesh, Nepal, Myanmar and Cambodia; and we will expand to Latin America in 2020.

There was also the first Merck Health Media Training in Kenya to break the stigma around infertility in Africa, may we know the reason behind the focus on infertility and liaising with the media?

According to WHO data 2016, one in every four couples in Africa and developing countries are infertile which means that there are 180 million couples that are infertile. Incidence is much higher than in Europe and developed countries which has around maximum 8% to 9%, very high percentage of infertility due to untreated infectious diseases which result from child marriage, unsafe abortion, unsafe delivery, STDs and genital mutilation. Hence prevention is very important.

More importantly, in many cultures women suffer discrimination, mistreatment and violence due to their inability to bear children, although 50% of infertility cases are due to male infertility, therefore we need to create a culture shift to respect women whether they are mothers or not, encourage men to speak up about their infertility and support their wives through the treatment journey. I strongly believe in the power of art and media.

They are critical partners to address such sensitive topics. We have produced many projects of songs, and now we are going to produce drama (plays and documentaries) with African talents across the continent. It will be the first and we will be creating a culture shift, raising awareness and exploring African talents.

We started “Merck More Than a Mother” campaign in 2015 now it is in 35 countries in Africa and Asia. In partnership with First Ladies who are the ambassadors in their respective countries, academia, ministries of health and international fertility societies, the initiative also provides medical education and training for fertility specialists and embryologists to enable them to help and treat infertile couples in their countries.

Also, part of the campaign is our Merck Embryology & Fertility Training Programme, a three-month hands-on practical course to establish the platform of fertility specialists across Africa and Asia. Merck Foundation provides clinical and practical training for fertility specialists and embryologists in more than 35 countries across Africa and Asia such as: Chad, Niger, Central African Republic, Cote D’Ivoire, Ghana, Ethiopia, Uganda, Kenya, Tanzania, Zambia, Nigeria, Benin, Mali, Burkina Faso, Senegal, Guinea Conakry, Sierra Leon, Liberia, Cameron, Rwanda, Botswana, DR Congo, Congo Brazzaville, Gambia, Nepal, Sri Lanka, Bangladesh, Myanmar and Cambodia. So far more than 80 candidates have taken the training.

How do you envisage the future of health care in Africa and the partnerships that Merck Foundation is forging across the continent?

I think the future will be brighter if we cooperate together. The magnitude of the health challenges are very big to be addressed by one organisation. The secret is in the private public partnership and to really get things done by being hands-on. No time for talking anymore. We need to talk only when we talk about our impact and way forward.

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