Queen Elizabeth 2 Government Hospital

Wednesday, December 19, 2007

Today was my first day as pediatric AIDS corps (PAC) doc assigned to the Children’s Medical Ward (CMW) at QE2. I can already tell that these are likely to be two of my most trying and memorable weeks during my assignment in Lesotho (though I think I get to do this again in 2008). This morning I met with Dr. Guada Richter, PAC pediatrician who was finishing her two weeks on the CMW. We rounded on the current list of patients that the Baylor docs are in charge of. Malnutrition, tuberculous meningitis, bacterial pneumonia, pleural effusion with shifted mediastinum, bacterial meningitis, impressive hepatomegaly, and gastrointestinal bleeding were some of the “run of the mill” diagnoses. Queen2 is rich in contrasts. It affords a wonderful teaching opportunity. The variety of diseases seen, the autonomy it provides (think of the opposite of inpatient peds at Sutter – when it used to have inpatient peds), the procedures – all bring amazing learning opportunities. I started my first scalp vein IV catheter on a baby that had poor peripheral venous access. I have no attending. More unbelievably, I’m the “private” referral doctor in charge of patients on the CMW of the national referral hospital. Yes, it’s ridiculous. I’m way out of my league.

I was rounding in the nursery, a small oven of a room with babies stacked in neat little rows lining the room – tiny premature babies, babies with communicable infections, all lined up next to each other in their cribs. It really catches your attention the first time you see a roach scurrying up the wall next to a row of cribs. I asked why my 20 day old baby with suspected meningitis hadn’t had his temperature recorded (this is normally done only once a day in the nursery at QE2).
“The thermometer (mercury) is broken”.
“OK, could you borrow one from the busy maternity unit next door (I’m sure it has hundreds of deliveries per month)”
“No, they don’t have one either”.
What? Wow. It turns out they can only get one from the pharmacy on Fridays and Mondays. Oh. I see.
Back at the CMW, I was starting an IV on a child on one of the two exam tables in the treatment room and looked over at a small, still form. A 4 month old child was covered with a sheet, left alone on the exam table. My first thought, Why is there a dead child on the procedure room exam table? Where is the mother? Why are the same tables that are used for lumbar punctures and initiating IVs also used for holding the deceased children? Why do children die on the ward almost daily? The child had been seen in the Casualty Department, our version of an emergency room and admitted to the CMW. While the child was waiting in his mother’s arms on the bench to see the admitting medical officer, the child died. No Code Blue called, no rush of doctors and nurses to bring the child back from the clutches of Death. Just a child that presented too late to the doctor due to a hundred reasons. I quickly (and coldly?) thought to myself, move on, keep working on your list of patients to save the ones that you still can.

Day 2

Really the morning of day 3 before work; I was too tired and depressed to write last night. Yesterday was a tough day. Rounding on patients throughout the day, catching up on things that needed to be done to the patients I was getting to know, admitting new patients, doing procedures. Blood that needed to be hung over night and wasn’t, meds that should have been given but weren’t. Kids in respiratory distress with only a weak hint of oxygen piping through tubing from an oxygen concentrator split between 3 kids. No ventilator for kids in respiratory failure. Bad attitude from nurses (How much can I blame them? They have too many patients, they see death all the time, and they get paid $8,000 a year). Still no thermometer in the NICU. A patient trying to kill a roach on the wall with her shoe. I expect at least a few kids to be dead this morning. Most of the deaths would be preventable in the States. Man, I’m already getting depressed.

The Weekend

Weekend rounding went more smoothly. I was able to see the patients and get out into the fresh air by midday. Going for runs, reading a book, trying to learn the guitar – all keep the sanity in my life during this tough rotation.

Holiday

Christmas Eve at the CMW was tough. Patients are often kept two to three in a single bed due to overcrowding. I was rounding on one of my patients (a child that had seized for an hour at home because the mother didn't have money for a taxi ride to the hospital - the fair was 50 cents) when the mother of the child sharing the bed started wailing. The translator told me she was crying because her child just died. What? I called for the other doctor, and we brought the child into the procedure room and started resuscitation. The attempt was futile. The heart had already stopped. There was no support staff. The was little equipment. The child had gastroenteritis and likely bacterial sepsis and died from cardiopulmonary arrest, due possibly to aspiration or electrolyte imbalance. There was nothing we could do.

Coming home that afternoon, I decided to go with my friends to the Drakensburg mountains for Christmas. This expansive mountain range runs through Lesotho and South Africa (SA), and we visited a resort in the central Draks located east of Lesotho in SA. We camped on Christmas Eve in a light, mesmerizing drizzle that soothed my hospital pains, and I stayed in a swank room the following night. Christmas dinner was OK, but it sure didn’t compare to the feasts at the Pierce house in Corpus. I thankfully was able to talk to the family as they opened presents and sipped on their morning coffee. Wednesday I was off from work for Boxing Day, a holiday that reportedly has nothing to do with fighting or underpants (though there is Dad in his undershirt; caught with my webcam!). We had a leisurely drive back to Maseru, stopping once again in Clarens for a little microbrewery reward, in celebration of Boxing Day, of course.

Back For More

Back from the beautiful Drakensburg mountains, I awoke Thursday morning with the intent of a run. The days can be long at QE2, so I like the idea of running before work. Unfortunately, the bed gravitational pull (BGP) was again too strong (perhaps the 3rd failed attempt so far while on the QE2 rotation). On the way to work, I was expecting the worst. I felt pretty sure that there would be at least a few of my patients that had passed away over the holiday. Believe it or not, all of the patients that I was in charge of were alive. In fact, most of them were getting better without me. It made me wonder if I should try coming to work every 3rd day more often. I was able to move all of the “sick” patients out of the acute room and into rooms where the more stable patients stay. I also discharged a number home. I am amazed how the reaction to the news of leaving the hospital is universal: giddiness, smiling, even occasionally dancing. I guess most people aren’t happy in the hospital. I suppose that includes me as well.

Note: Roach count today - 2 in the nursery, only 1 on the children’s ward.

While I was seeing my patients another child with advanced diarrhea died. Eerily similar to Christmas Eve, I was rounding on my patients when a mother started wailing. Resuscitation attempts were again futile. This time I realized that we do have some suction available. It is a plastic looking contraption that you have to pump with your foot to create a weak suction. This “code blue” and aftermath were so starkly different from similar events in the US. A nurse would briefly come in the room and then leave. It’s as if they have no training in resuscitation, almost as if they are afraid to be involved. The medical officers found the medications, and drew them up in syringes; there was no one from lab (“stat labs” mean within the same day), no one from x-ray (no portable x-ray device that I’ve seen), no intensive care expert from the ICU to lend a hand (no Jim Gude or Ken Lamb; no Bombers). Just fumbling with worn down equipment, expiring medications, and apathetic staff. The environment in the acute room where the child had been staying was also sad and intriguing. The mother was not taken from the acute room after the death (though I offered; there is no “quiet room” for families of the deceased); instead she stayed there, crying while the other mothers fed their babies, changed their diapers, and joked about various things. Though childhood death is so common here, there seemed to be no camaraderie among the mothers (I expect this had something to do with her being new to the ward). The doc who had seen the baby in the morning didn’t stop rounding on her other patients, so I did what I could to help console the mother.

For a further look at QE2 in the news:

CNN online special that mentions Queen Elizabeth 2 hospital (check out: http://edition.cnn.com/video/#/video/international/2007/12/05/inside.africa.hope.for.aids.orphans.cnn?iref=videosearch)
You can also see the recent (though fairly inaccurate) LA Chronicle article on Queen 2 and Bill Gates funding (see: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/12/16/MNJFTVFK3.DTL).

Friday and Saturday

I’ve been getting more into the swing of things. There have been several days without an admission, there have been fewer IVs to struggle with (I’ve become best friends with IM ceftriaxone), and I’ve had a chance to discharge some patients. Discharge basically comes down to: the patient no longer needs IV meds or oxygen? Ok, pa' la casa - they’ll probably do better at home. I’m sending patients home in worse condition than I would in the States, but with the lack of quality nursing care (there are medication errors every day) and infection control (I’m almost the only staff person that washes his hands) I feel the hospital is a danger zone, a ticking time bomb. We’re working with the medical officers and the nurses, giving suggestions and the occasional lecture, but we’re not in the position to make major changes. I wish we were. Take, for example, the 12 year old girl that has been walking around the entire CMW. She plays with the other children, jokes around with the nurse and the patients’ parents, goes up to the medication cart and receives her meds along with the other patients. She wears a surgical mask. Why, you might ask? She is being treated for pulmonary tuberculosis for the third time and still has TB in her sputum. She most likely has multidrug resistant TB (MDRTB), a form of TB that is very difficult and very expense to cure, even in the US. Her mother doesn’t visit often, so she gets lonely in her “isolation room” with is about the size of a closet – similar to what I imagine solitary confinement cells are like in prisons. The docs and nurses have all tried to keep her in her room but sympathize with her loneliness; she therefore has been allowed to pretty much do as she pleases. I called a meeting of the staff and talked with the child. We made a compromise where she is allowed to be outside in the little playground when she isn’t in her isolation room (TB is very hard to catch when you are in the open air). Also, I bribed her with a cookie. We’ll see how long the deal lasts.

I’ve got 5 more days to go on this rotation. I’ll let you know how it goes.

A story about the Mission Aviation Fellowship that flies docs around in Lesotho just came out in the Houston Chronicle. Our work in Mokhotlong is mentioned in the article; make sure to also click on the audio slideshow. Smiley Pool (photographer and longtime comrade to the PAC and BIPAI) did an awesome job.

http://www.chron.com/disp/story.mpl/life/religion/5408265.html

Take care,

Jeff

Wow, finally!

Finally, A New Blog Entry!

It’s hard to believe it’s been months since I’ve updated the blog. I’m not sure why it’s taken so long. The work here in Lesotho has become a little more involving, and in addition we seem to be traveling every weekend. I’m not complaining. It keeps us out of trouble, I’m sure. The good news is that we now have high speed internet at the house, so I should get a little better at keeping you informed (I know you’ve been on the edge of your seats). Included in this blog entry are more details and pictures from the outreach work in Mokhotlong, an HIV testing event, weekend trips to South Africa, and my vacation to India.

Second Trip To Mokhotlong
October 21 – October 26

This time the scenic trip up into the Maloti mountains was undertaken by a group of four: Paola Peacock-Villada (Clinton Foundation), Tony Garcia-Prats and Heather Draper (Baylor), and myself. The Clinton Foundation works internationally to obtain more affordable prices for HIV meds and testing supplies. Some of Paola’s work has included increasing testing of HIV positive children under 18 months with the DNA PCR method, improving access to care, insuring good follow up after diagnosis is made, and helping to streamline the labs across the country so that crucial lab monitoring is available. The PAC doctor’s work would be impossible without the hard work put in by the Clinton Foundation.

Again as we headed up the mountains we were greeted by heavy clouds, though this time they only released a light drizzle instead of hail. Though later we rounded a bend and were awed by an expanse of freshly fallen snow! Snow in Africa as spring turns into summer. Amazing.

At the end of that first Monday, I felt like I was already getting more done than my first time in Mokhotlong. I spent more time working with the nurses of the maternal child health clinic and the maternity (labor and delivery) ward. Regardless of overtime or effort, nurses at this hospital earn next to nothing (yes, even Sutter Santa Rosa pays more). There are 5 maternity nurses, one on overnight at a time, pulling 12 hour shifts. There are over 100 deliveries a month, and the nurses, who are all trained as midwives, do just about all of the vaginal deliveries. For the most part during the night shift, the physician on call is just called to perform cesarean sections [and they aren’t even obstetricians…shocking! (said with sarcasm)]. The physicians still write the orders (like inducing with 50 mcg of misoprostol; they only have the 200 mcg tablets so they can only break them down to quarters; though it’s better now…most of their inductions were failing possibly due to expired Cytotec), perform the ultrasounds (I was teaching them how to do 3rd trimester biometrics – measuring various fetal parts to help determine how far along the pregnancy is; thank you Tom Neal), and of course perform operations like tubal ligations, etc. I have heard conflicting information about pregnancy terminations. A doctor in Maseru told me it is a legal procedure, and she does them at her private clinic for roughly $200 dollars (remember that the average income is less than 2 dollars a day here). One of the Zimbabwean docs working in Mokhotlong says he was told that it was illegal (women have been brought to the clinic by police after having an abortion), and it seems no one in this expansive district performs them. Some women go across the border to South Africa to obtain the procedure. I haven’t seen any septic abortions come through the maternity ward, but with access as limited as it is, I won’t be surprised when I do.

One morning I walked onto an interesting scene. I found a lone nurse in the delivery room scrambling to get oxygen and suction started for the struggling baby she just delivered. I took over the resuscitation, while the same nurse returned to the new mom who was lying naked on a rubber sheet that covered a foam “mattress”. Not changing gloves, she took out the needle and thread and started repairing a 2nd degree laceration. She was a little flustered when, wide-eyed and open-mouthed, I asked her if they always did the repairs without local anesthetic. She shuffled around the room looking for lidocaine, found it, then went back to the repair (same gloves on) without using it. Wow, that patient was sooo stoic; she just made faces and a few quiet grunts. Amazing. I didn’t like it; but amazing none the less. Following the repair, the patient put on her dress, picked up the baby, and walked out of the delivery room and over to the communal post partum room. I’m not sure, but I don’t think she had a birth plan.

Soccer with the princes

The PAC docs and the clinic staff helped test and screen kids at an awesome HIV testing event/soccer tournament in Mohale’s Hoek, Lesotho, organized by our friends David, Pete, and Paola. Prince Harry of England and Prince Seeiso of Lesotho, whose charity organization Sentebale (meaning “Forget-Me-Not”) was involved, popped by in their helicopter to watch HIV education and testing practices. See attached pic of the prince with Baylor docs Kathy Ferrer and Edith Mohapi, as well as Paola and Pete. Check out the Sentebale website for more info: http://www.sentebale.org/home/index.html


Arrival of the visiting scholars

I was very happy to see my old UT Pan Am alum and friend Yvette Almendarez and her pediatric colleague Ashley Cox arrive safely in Lesotho. They are both Baylor Med School grads and are in their final year of pediatric residency at Texas Children’s Hospital in Houston. They came to learn a little more about pediatric HIV, help us in the clinic, and see the sights of southern Africa. Mostly they just called John to fix their plumbing and fight off squirrels in the attic at 3 in the morning. But that’s too long of a story for now. We took another day trip to Clarens, the quaint town in South Africa that has good cheese and beer on tap. Sounds strange to travel to another country for cheese and beer, huh? Well, not if you know me. This picture is us in our car on top of a moving tow truck. Read on for more details. Yvette and Ashley are back in Houston now. Thanks for coming guys and good luck; we miss you.

3rd trip to Mokhotlong

Following an interim “routine” week seeing patients in Maseru, I made the trip out to the mountains again, for the first time going it alone. It was slightly romantic, being the lone doc in his 4x4, slowing winding his way up the mountain roads between remote villages, greeting sheep herders and dodging sheep dung. This picture was taken on the way back from Linakaneng. The animal is an nku (sheep; maker of sheep dung). Along with the African docs assigned to Mokhotlong city, I saw children in the children’s medical ward (CMW), adult inpatients, and patients at the dedicated Lerato (meaning “love” in Sesotho) HIV clinic. This is the clinic that is a smidge bigger than a closet, but with fewer resources. I drove out to the rural health centers of Libibing, Linakaneng, Malefiloane and Mapholaneng. The roads are unpaved and super rocky, but wind through gorgeous terrain – one of the best commutes in the world. There is always plenty of variety in the conditions the people have to face (usually more advanced in their course and always with fewer resources available to diagnose and treat them). To name a few, I saw 2 likely new cases of lupus, gestational hypertension, a kid with total body swelling due either to malnutrition or kidney disease, active tuberculosis (so common that it’s routine), and conditions associated with the weakened immune system caused by HIV infection. Every day is different, offering the chance to work in the hospital and outpatient setting, do home visits, deliver lectures, mentor nurses and docs, and perform tough blood draws (including external jugular and femoral vein blood draws on infants).

Reunion in Joberg

Thanks to the planning and hard work of Seema, the medicine/pediatric PAC physician – gourmet chef – vacation planner extraordinaire working with us in Maseru, several of the PAC docs from around southern Africa got together to enjoy museums, food, caipirinhas, dancing, and the occasional irritant gas bomb (random). As Yvette and Ashley will attest (they will, just ask them), the trip from Maseru to Joberg was a bit hectic. While driving the car on the highway Anu realized that the clutch pedal stopped working, and he could no longer change gears. While theoretically we could have completed the remaining 3 hours to Joberg in 5th gear, it was his better judgment that had him pull off to the side of the road. Thanks to our South African car insurance, we were quickly towed to a “24 hour station” manned by some of the toughest looking men (and women) of the Free State (the name of the South African state in which we were stranded). I wish I had a picture, but the leader, a huge Afrikaans guy, had the most impressive mullet I’ve seen in Africa. They were great, and actually worked on the car for about an hour on a Friday at 8pm, eventually replacing a broken seal and getting us on the road (for an amazing $70 US) in time to meet the rest of the group for dinner in the Melville district of Joberg. The picture is not actually of the garage crew but two sexy hunk Botswanan PAC docs - Jonathan Bernheimer and Paul Mullen.


Two weeks in India

I had the pleasure of joining Anu and his parents on a whirlwind trip of southern India. Anu and I flew via Emirates Airlines, leaving on a red-eye from Joberg to Dubai, the capital of the United Arab Emirates (I actually remember learning about that country in Mrs. Putman’s 6th grade Social Studies class) and on to Mumbai (which is not, strangely, the sister city of Dubai, but did used to be called Bombay) on the west coast of India. Anu’s family was truly wonderful, treating me like part of the family from my first moments in the country. This was my first trip to India, and was it ever much anticipated. Since going to med school, where 80% of my friends were 2nd generation Indian-Americans (not to be confused with American Indians, Native Americans…or Pakistanis), I have been in love with what I have learned of the culture. The colorful and flowing saris, the permeating presence of Hinduism, Christianity and Islam, the music, and the food (ahhh, the food) were richer than I had anticipated. I was impressed with how much more crowded it is compared to Africa, especially Lesotho (I imagine much of Nigeria might be more similar to India in this respect). There is little possibility to get away from honking horns, city lights, and jostling crowds – even in the relatively less populated south where we were traveling. Anu’s parents, originally from India and currently living in Midland, TX, set a busy but enjoyable pace. We took several night trains, and I experienced first hand the difficulty of voiding on a bumping Indian train. I also saw more rats (Anu insisted they were just mice) among the tracks one night than I might have seen in all my life. Just imagine that scene from “Indian Jones And The Last Crusade”, then imagine world peace. Well, why not, you were already imagining, weren’t you? We traveled through 6 states: Maharashtra, Goa, Karnataka, Kerala, Tamil Nadu and Andhra Pradesh, went to a family wedding at the Tirupati temple (so much gold and sooo crowded), hung out at a hill station in Coonoor, and motored and slept on a house boat in Kochi. By far the most amazing experiences were the meals. I had so much masala dosa,
idli, vada, chapatti, sweet lassi...and thank goodness, never got sick...as far as I know. Well, I guess maybe a course of mebendazole before things “mature” might be a safe strategy.

Dubai

On the way back we spent a day and night in Dubai. Besides a few sneaky merchants and a sketch hotel, it was a great experience. I loved: the savory hummus, extra helpings of falafel, a coast with a warm breeze reminiscent of Corpus, hanging and speaking Spanish with a Colombian back packer, eating Dunkin Donuts, seeing a Hardees, and gazing at a beautifully lit mosque at night.








Back To Africa
Since coming back from vacation things have been moving fast. I’ve been back to Mokhotlong (check out the pics of A Tale of Two Cellulitis Cases: two women in red dresses in two different cities presenting within a week of each other with right hand cellulitis; the child in the picture has typical lesions of scabies), where I continue the tradition of transporting more people with active pulmonary TB in the back of the Land Cruiser. I stayed at the Louis Gregory Center this time - a farm in a gorgeous valley (pic of the house included). I’ve been traveling on the weekends, and the clinic schedule during the week in Maseru is getting busier (we saw about 155 patients today in clinic). I’m hoping things will slow down a bit during Christmas. I’m having a little difficulty feeling the holiday spirit during the summer in a country that doesn’t really deck the halls. I’ve certainly felt more homesick around the holidays, as Thanksgiving and Christmas are celebrated in full regalia by the Pierce clan. Similar to last year, where during residency I had the good luck of being on inpatient medicine call (albeit with some awesome fellow residents) for Christmas Eve and New Year’s Eve, I’ll be the PAC doc assigned to the Children’s Medical Ward at Queen Elizabeth 2 (QE2) hospital. While being around kiddos during the holidays is usually a welcome opportunity, unfortunately it seems half or more of the kids we admit to QE2 die during hospitalization. Infant and child death is so common here. This specific contrast between here and the States will always simply blow me away. The death toll certainly wears on you, whether you’re a visitor or a local (a South African nurse’s child told her, “you don’t smile any more”). But every day that we see a baby or her mom die of malnutrition or TB, we see a hundred more that are healthy, running around, gaining weight, and smiling thanks to the medicines and the people that we work with. I am so grateful to have this opportunity and continue to realize that I get more out of it than I contribute.

Miss you all very much,

Southern African Adventure

Back From Abroad


Hello. I hope all are doing well. I’ve been traveling a lot over the last 2 -3 weeks, so here is some catch up blogging. The first entry speaks of some of the variety we've been seeing in the clinic, followed by a description of my first trip to my rural assignment, the mountain city of Mokhotlong. Lastly I write about our trip to Swaziland for a conference with a little vacation on either side of it, magnificent Kruger National Park and the suave and vibrant Mozambique!



Tuesday Variety Show

I saw a great variety of patients on one Tuesday at the COE. I’m so happy that I’m starting to get some continuity (patients that I've seen on more than one visit). Started off with a pregnant woman I’ve seen a few times now. She sticks out because she voices her opinion and asks a lot of questions. She’s on HAART due to having a low CD4 count and is about halfway through her pregnancy. We started addressing some of the tougher issues: scheduled cesarean section versus vaginal delivery, for one. That one I can say pretty strongly that a routine vaginal delivery is the preferred route, as her HAART will give her child around a 98% likelihood of delivering an HIV negative infant. Formula feeding versus breast feeding is a much harder issue. Yes, she can probably afford the formula, but that still puts the child at a risk for higher mortality due to other infections, particularly diarrhea and upper respiratory tract infections. No easy decisions there.

Next saw another woman I’d seen before, this time no longer pregnant but a beaming new mom with her one week old baby. She delivered after being on the PMTCT regimen of Lesotho, which is based on the WHO guidelines for resource poor settings. She took AZT from 28 weeks, took her Combivir and sdNVP properly during labor, dosed the newborn with a squirt of NVP followed by AZT syrup BD. So tough to then see that she’s breastfeeding this child, increasing the chance that it becomes infected with HIV, but decreasing the chance that it’s going to die from other causes in the neonatal period.

Later I saw a middle aged woman with possible Ramsay-Hunt syndrome (herpes zoster oticus). She had a few days of fever, L sided ear pain, L sided hearing loss, decreased sensation on the L side of her face, and L sided tongue tingling and taste changes. She had no facial droop or lesions in or around her ear. Seems like either HSV or VZV can cause this. I started her on acyclovir and hope that it helps.

Another mom, this one had weaned the baby off of breast milk, and was now giving only soft porridge for the last 2 weeks. Couldn’t afford formula, couldn’t afford trips to the clinic, couldn’t afford insecticide to kill the fleas that were biting the child (though maybe those were from scabies, since I’ve been itching all night).

Lastly I saw the first presentation of both a mom and child that were both so sick they both got admitted to the hospital together straight from the clinic. The woman had a long hx of cough, fever, and TB exposure (but who doesn’t in Lesotho?) was febrile, was breathing almost 40 a minute, O2 sat around 95%, with L sided decreased breath sounds, dullness to percussion and egophony – most likely pulmonary TB with pleural effusion. The child was admitted for severe malnutrition, dehydration, and sepsis.

First trip to Mokhotlong

Tony Garcia-Prats and I made the 5 hour road trip to Mokhotlong, high up in the mountains of eastern Lesotho. We drove through some pretty amazing scenery. Once outside of Maseru, we were greeted by vast expanses of tan, brown and golden fields highlighted by solitary deciduous trees and small thickets of evergreens along the side of occasional rock outcroppings. The peach trees are still providing their pleasant contrast of spring pink flowers in this rather mute background. The real beauty began once we entered the mountains. Overcast skies with pregnant clouds lay low over the peaks of some very impressive mountains. The road was winding but well paved, and the drive was peaceful and quiet, interspersed with yells from smiling kids running along the road when they saw the pale faces. The steep slopes were dotted with small sheep herds and their herders – young men wrapped in traditional blankets and carrying walking sticks. As we drove higher, the air became cleaner and crisp. When we reached the summit, the sky opened up – releasing pea sized hail in droves. We pulled off to the side of the road to enjoy the storm. As the bolts of lightning became more impressive, we decided that being at the highest point of the mountain was not a great idea and began our descent. We passed the one and only Lesotho ski resort (a single slope with a rope pull that was currently devoid of snow), and besides a lot of rain, we had an uneventful remainder of the trip.

The Mokhotlong District Hospital

Maseru is divided into 10 districts, each with its own district hospital and associated health centers. We found the hospital and grounds to be in very good condition. I was pleasantly surprised to see that the hospital was in a much better state than the run-down central government referral hospital in the capital (the Queen Elizabeth 2 Hospital that I’d mentioned prior). The hospital grounds incorporate adult women’s and men’s wards, a TB ward, maternity ward, maternal child health clinic, the Lerato HIV clinic, a pharmacy, and an outpatient department. Though there have been times that the district has been without skilled doctors, currently the area is fortunate to have 5. There are two Zimbabwean doctors, Dr. Nyamutukwa and Dr. Munzararikwa, two Cuban docs assigned for a 2 year contract, Alberto and Francisco, and Dr. Karumba, a physician from the Democratic Republic of Congo. The African physicians cover the hospital and the Lerato HIV clinic, take a week of call at a time, and do necessary procedures. The Cuban doctors see only the outpatients and do not take call, in part due to their lack of Sesotho language skills and limited English. Some procedures that were being provided the days I were there included chest tube placement for empyema, cyst excision, cesarean sections, orchiectomy for testicular torsion, and closed reduction of fractures. The c-sections are most often done under conscious sedation with ketamine administered by a nurse (scary, if you’ve ever seen someone start to come out of ketamine sedation during a painful procedure). At least one of the providers can do spinal anesthesia, but they avoid it since there are no working laryngoscopes or endotracheal tubes for intubation in case of a complication such as a “high spinal”. The lab is rather well set up. It can run CBCs, LFTs, urea, creatinine, CD 4 (a new and potentially very important machine to check the strength of a patient’s immune system, but no reagents yet and can only do about 15 tests a day). The microbiology capability includes gram stain and culture of infected secretions, urinalysis and microscopic evaluation, smear for acid fast bacilli, CSF gram stain and India ink evaluation. There are no blood or CSF cultures, no electrolyte machine, and no other “fancy tests”. Diagnosis of HIV in children less than 18 months of age needs a special machine that doesn’t exist in the area (nor in the entire country). We send dried spots of blood on a special paper card by DHL mail to South Africa, receiving the results in 4 -6 weeks.

Lerato Clinic

The one clinic on the hospital grounds that sees HIV positive patients is also the smallest clinic on the campus. It has no electricity, no water, 3 rooms (waiting room/vitals, nurses’ room/counseling room, doctors’ exam room/blood draw room). Besides the small waiting room, there is no place to get out of the rain (they built a covered waiting area but it caught fire the day after it was finished). I saw a woman at the end of the day who had missed her period, had new onset lower abdominal pain and a new vaginal discharge – but no pelvic exam (I was seeing her in the nurses’ room which had no bed or table, and it was twilight and we had no electricity), no urine pregnancy test available at that time of the day (to help evaluate for possible ectopic pregnancy). Luckily she lives so far away from the clinic that she had to find shelter in town. At least she should be able to make her way to the hospital if it is an ectopic that gets suddenly worse tonight. The last patient of the day was a woman that “had no problems, just here for medicine refill” according to the nurse. A quick glance by the almost non-existent light of dusk showed that her CD4 count had been steadily decreasing while on anti-retrovirals. This suggests that she “has a problem” and shouldn’t just be getting a medicine refill. Luckily she also wasn’t able to get back to her mountain village and will be seen tomorrow in the daylight.

“Rural” Health Clinic

While Mokhotlong is far removed from the capital of Maseru, it is still a sizeable city. We jumped in the UNICEF Land Cruiser and visited the health center in the small town of Libibing (pronounced: Dibibing). Here, there is a small health clinic staffed by a nurse, a nursing assistant, and a social worker – much more support than most clinics of its size. Besides a room to see patients, they have a basic pharmacy, including recently accrued antiretroviral meds, a few beds, a delivery room, and two waiting areas that can also be used for patient education. Just when I thought this was the end of the line, it seems like patients still have to walk long distances to be seen here – even up to 3 to 4 hours. I asked a woman how long it took her to walk to the clinic and she answered poignantly – it depends if I am health or sick. We went on two days, saw patients with the social worker and the nurse assistant (the nurse was out of town at a training) and encouraged the patients and their families to be tested for HIV. There are another 6 rural towns in the Mokhotlong district with health clinics, and unfortunately we didn’t visit any of them on this trip. The next sojourn up to Mokhotlong will be in mid November, and we plan on addressing many issues, including: PMTCT (what is being done in the rural clinics as well as the district hospital), visit the remainder of the rural clinics, plot out where and how we will be building the new BIPAI funded family HIV clinic on the district hospital campus, attempt more testing to diagnose HIV positive children and their family members in the rural periphery, and continue to train the local doctors, nurses, nurse assistants, social workers, and community health workers/expert patients. I liked the feel of the area, and I think we’ll be spending more time up there – maybe a few weeks at a time.



Happy Hour In Maseru: Jowling Update

Still lots of work to do with the Lesotho Jowling team.

Kruger National Park

We took off Thursday morning, October 4th, to Kruger National Park in north east South Africa. The group was made up of myself and Anu, along with the 3 current Lesotho visiting scholars - Megha Patel and Amit Singh, two visiting med students from Baylor, and Djin-ye Oh, a visiting resident from Germany. Thursday was Independence Day in Lesotho, so the line was long, even at 8 AM, at the border crossing. In line we met a small group of Peace Corps volunteers, getting away for a little much needed R and R themselves. The drive from Maseru, Lesotho, to Hazyview, the little town outside the southern portion of Kruger Park was a little long but filled with some beautiful vistas. The early portion was the same road we took to Clarens a few weeks earlier – magnificent buttes jutting out of a rolling, light green and tan landscape. There was a stretch south east of Joburg that reminded Anu and I of West Texas – pretty brown, pretty flat, and not too exciting to drive through. But just within an hour of that we got into a valley that started out like Sonoma County – complete with “golden” hills, then with eucalyptus and then evergreen trees. The main differences from northern California were the street signs - like “hippopotamus crossing” and “Crockadile River”, etc.
We stopped for a great dinner at “The Fez at Bagdad”, a great fusion restaurant in a fancy little area of White River, the town outside of Hazyview. After 7 hours of driving, we feasted on bruchetta with soft goat cheese, great 12 dollar bottles of wine, a warm pumpkin/feta/lime-infused red onion and pine nut salad and chocolate polenta cake.
We rolled into “Hazyhaven”, a pleasant little bed and breakfast in Hazyview, run by Dawie and Shirley Malan. We definitely feel like we lucked out – all of the places we were calling the night before our trip were either closed, full, or too pricey. Hazyhaven turned out to be clean and cozy, with a pool, and breakfast provided, all for about $35 a night.

Big Animals

We spent both Friday and Saturday driving around Kruger Park. Instead of being in a big safari 4x4 driven by a local with a blunderbuss, Kruger allows you to drive yourself in and do a self-guided tour. It’s hard to describe the feeling of seeing animals outside your car window that you’ve only seen in zoos or on the television. Day 1 brought my first sights of big African animals. These animals really are big. The experience was amazing. Within the first few minutes of entering the park we came across a group of baboons. We pulled to a stop and watched them play in the trees and amble across the street. Just a few minutes down the road came the first views of the deer-like impala (but with horns instead of antlers), followed by the impressive kudus (almost the size of elk, with spiraling horns). Our first sighting of an adult giraffe blew me away. He walked across the road right in front of our car, ate some leaves off of a tree, and then continued on his way. We were lucky enough to also get really close views of an adult male elephant and a pair of white rhino (all of which at one point seemed on the verge of getting too close to our little Volvo). We also captured our first views of zebra, vervet monkeys, hornbills, storks, crocodile, and hippos. The second day, we were joined in the park by our new friend Ursula Jessee, a hip chick living in Joberg who is currently doing research on evicted people there. Under a grey-blue overcast sky and occasional showers, we had a sighting of a beautiful leopard, hippos out of the water, and a family of hyenas (the mom, big and more than a bit scary, approached Ursula’s very little rental car as she smelled the kudu jerky that had been ripening in the car for the last day). After an amazing day of seeing these peaceful animals enjoying existence with their families in their natural habitat, what a better way to wrap up the day than order up some mama kudu for dinner, medium rare. Well, that’s what the carnivores in the group did – I found the shiraz much more appealing.

Jerry Goes to Kruger

As we were on our way to a Baylor International Pediatric AIDS Initiative meeting in Swaziland, we were transporting a mannequin – a roughly 12 year old boy CPR mannequin that we named Jerry, to be exact. After a few hours of fruitless searching for the elusive cheetahs and lions of Kruger, Jerry came out of the trunk for his first views of big African game. He was a little unnerved at first, but much less so than the people in other cars who got a glimpse of our shannanagans (I just realized that I have no idea how to spell shinnanegans). I’d say he had a really good time (see attached photos). The highlight was when we passed him through the window between our cars (it’s illegal to get out of your car at Kruger, for obvious reasons). We think it was also the highlight for the woman in the car behind us.



Baylor International Pediatric AIDS Initiative Network Meeting

Anu, Ursula and I said good-bye to the visiting scholars as they headed back to Maseru, and we headed over to Swaziland. Like Lesotho, Swazi is one of the few remaining kingdoms in Africa, and similarly is in a state of crisis due to the HIV epidemic. With a population of nearly 1 million people, it has the world’s highest percentage of people living with HIV – around 40% in pregnant women and even higher in some age groups (I believe 1 out of 2 people aged 24-29 are HIV positive). As more people get sick with HIV, health care needs increase, but health care capacity is simultaneously falling – there are fewer doctors and nurses alive to take care of all the sick people. The life expectancy just five years ago was 60 years (the US is around 67 yrs). Currently the life expectancy is only 31 yrs of age. Around 70% of the population lives below the poverty line – this is living on less than a dollar a day. There are about 76,000 orphans (about 1 out of every 4 children). This would be like the US having 18 million orphans. Swazi is also known for its laid back pace, natural beauty, and the tradition of polygamy. To make the dire health care situation in Swazi even worse, many of the government officials, including health care leaders, are appointed by the king, seemingly irregardless of their skills and lack of training. Anu and I came to Swazi since we were traveling to attend the Children’s Clinical Centers of Excellence network meeting in the capital and second largest city of Swaziland, Mbabane. We checked into our rooms at the Ezulwini Sun Hotel, a somewhat less ostentatious hotel in the swanky international Sun Hotel chain. The conference was attended by doctors from the 9 countries within the BIPAI system (Swaziland, Lesotho, Botswana, Malawi, Burkina Faso, Uganda, Tanzania, Libya and Romania). Much was shared between groups and hopefully the care of HIV positive children and their families will be improved because of the effort.

Mozambique: Nao e tudo bem!

Ahh, Mozambique. What can I say? Moz was more than I had expected. It is one of I think only two Portuguese speaking countries in Africa, the other being Angola. Immediately upon crossing from Swaziland into Moz, you could feel a difference. The energy of the country – its people, culture, and food to name a few points, was a level above. Moz, as some of the gringos call it, is definitely the most Latin American feeling place I’ve been to in Africa. The Holiday Inn, where the people with foresight stayed, was a beautiful beach front hotel unlike any Holiday Inn I’ve ever stayed, complete with a pool overlooking the Indian Ocean. I definitely recommend it as a great place to chill with a local brew, perhaps a Laurentina Clara or a 2M beer. A fellow PAC doctor working in Lilongwe, Malawi, Chris Buck joined Anu, Ursula, Anouk and me at the Hoyo Hoyo hotel, which was Spartan, to say the least – closer to solitary confinement to be more descriptive. We had a lot of fun speaking Portuguese mixed with Spanish and English, enough to maneuver around the city and get moderately ripped off by the merchants. The dining experience was great for the carnivores but left a lot to be desired for those of us who don’t like hurting the little fishies. Regardless, the fish market was an impressive place, with row after row of fish, large and small, shrimp, octopus, lobster, crab, prawns and mussels. You could walk through the market, pick your kill, and they’d take it back to the kitchen, douse it with butter, lemon, salt and other spices, and bring it back to you on a platter, fresher than anything you’ve seen at Red Lobster. A number of the group almost registered as permanent Mozambican citizens just so they could eat there a few times a week. We went to a night club looking for glimpses of the famous dancing skills of the mozambicanos, but were disappointed as three separate djs on separate dance floors played their own mixes of bad and worse electronica and hip hop. For their credit, the locals could dance well, just not to the music I was hoping to see them dance to.

On Saturday, while bargaining with over-zealous artists in the local craft market, I got a text saying that part of our group was relieved of their cameras by some of the local miscreants (who were possibly rugby enthusiasts). Luckily our folk were relatively unscathed, though it seems that when you finally find the police station to report the incident, the officials aren’t particularly likely to rise to the occasion (a huge surprise to the readers out there who have traveled in developing countries, I’m sure).

My respect for the law was not strengthened when we were stopped later that night for making a “mildly” illegal U-turn. The three cops were on foot and only had one AK 47, for the record, so we could have likely gotten away, but instead we decided to talk a little while with the nice gentlemen. To his credit, Buck did a decent job with the bargaining game. He was able to negotiate the cop down from a 150,000 US dollar fine, a trip to the station, plus having his passport revoked – all the way down to a whopping 12 US dollar fine. I wish I had negotiated that well at the crafts market.

On the way back, we enjoyed a glimpse of a zebra at the outskirt of a park, wishing us good bye from northeastern South Africa. It was a good 10 days away from Lesotho. To travel is nice, but it will also be good to start seeing patients again. There is so much to be done, and I often feel the pull to get back to it while away from the clinic. I also feel very fortunate to have the ability to travel. Such a small percentage of the people living on this continent can do so. So much beauty abounds here, from sunsets on a Mozambican beach, to baby giraffes grazing with their mothers, to mountain scapes stretching across the land of the Basotho. In 10 days I’ve been able to see all of these things, with relatively little hassle, and for little money out of my pocket. The disparity is brought home more emphatically as we drove past the shanty towns outside of Joberg. It’s not fair. Not at all.

Sick patients, the Mohale's Hoek and Jowling

September 17 - September 23

Clinic

I started the week off in the COE (center of excellence), the main Baylor clinic, and then worked a few days in the Bophelong clinic. Bophelong, attached to the Queen 2 hospital, is the first pediatric HIV clinic in the country and was in part sponsored by the Clinton Foundation. Mondays at the COE are our busiest days, more so than in the States as patients and their families use the hospital ERs less (more roaches and fewer doctors than our ERs). As is starting to be the routine, I grabbed patient files from the “family” box; these are usually adult women, sometimes pregnant, sometimes also here with one or more of their HIV positive kids. We are seeing some adult men, but most of them go to other community clinics. Patients coming for their first visit to the clinic are often quite sick. Due to a mixture of factors, including lack of knowledge of their diagnosis, denial, and poverty, they often have very weakened immune systems and the various infections that go along with those lapsed defenses. On Monday I saw an adult woman who was new to our clinic. I could tell right away that she was very ill. Pale and trembling, she slowly met my gaze with a mostly vacant stare as she was led by her much more attentive mother (so often the grandparents are the healthiest ones in the family, as they have escaped – for the most part – being infected with HIV). Ironically, the woman’s small child was already a patient at the clinic, on meds and doing well; she had made sure her daughter was in care but had not been able to get herself tested and enrolled in care. With a constellation of symptoms including confusion, fever, weakness, cough, vomiting and diarrhea I knew that there would be no straightforward diagnosis, especially with our relative lack of available tests. We scratched our heads, thinking that her advanced state could have been due to a myriad of opportunistic infections, including tuberculosis, mycobacterium avium complex, pneumocystis jiroveci infection, cytomegalovirus, systemic fungal infection, toxoplasmosis, cryptococcosis, or just HIV itself. We drew blood and CSF (no manometer to gauge the opening pressure, but in retrospect it looks like you can just use IV tubing attached to the end of the spinal needle and then measure how many centimeters of elevation the pressure of the leaking spinal fluid causes) for what tests we have available, started empiric antibiotic therapy, gave her a request for a chest X ray from the public hospital, and sent her out, hoping that she’d be able to return the next day for follow up. I definitely would have admitted her to the hospital if we had been in the US. She came in each day to the clinic as we drew blood for a few more tests and added more and more antibiotics – treatment for as many of the infections that she could possibly have based on her signs and symptoms.

Last week in the clinic I saw some stuff that floored me. There was a post partum hematocrit (NOT hemoglobin) of 8 which was drawn AFTER the one unit of blood available for her at the hospital. We had to drive out and find her in her one room home as she was an OUTPATIENT. She was not quite, but almost, as pale as I am - though her S4 and tachycardia were much more impressive than mine. The next day we took her to the hospital for a blood transfusion but she left because her baby was hungry and the line at the ER was too long. I saw a child with a multi-dermatomal herpes zoster scar that was so bad I thought for sure she had been burned in a fire. I saw an adult with a new diagnosis of AIDS and an absolute CD4 lymphocyte count of 3, as well as a child with HAART treatment failure whose CD4 percent had dwindled down to 1% (severe immunosuppression is defined as 15% or less). Saw another 9 year old in the outpatient clinic who was as tall as a 4 year old (probably due to a combination of HIV, malnutrition, and repeated infections) and had a CD4% of zero.



As an add-on patient at the end of the day I saw a young girl who had fever, cough, and night sweats, had recently been treated twice for pneumonia but never improved, had multiple family members that had lived in the same house as her and been treated or died from TB, and whose parents both had fever, night sweats, cough, and weight loss. In the US, with the very first case of active TB, a public health organized contact investigation would have been initiated, and the children in the house would have had a work up and possibly been started on treatment or prophylactic medications depending on symptoms. Here, there is no such thing, and unfortunately we’re getting kids that show up during or after treatment for their parents has been completed. We started her on presumptive TB treatment, gave the parents a slip for chest x rays and sputum samples to see if they are truly infected, and just hope that they actually do what we recommend. They might not go for diagnosis or treatment if they don’t think it’s really that important, if they can’t afford the time off from work, or if they think that a faith healer is all that is really necessary. In the meantime, if the symptoms they have are do to TB, they’re infectious and will be coughing on family and friends, spreading this biblical disease as it has been done for centuries. It’s so amazing that little has changed in our ability to combat this scourge. And we’re starting to lose ground, as HIV multiplies infectability and then transmissibility, not to mention the problems that we’re seeing with multi-drug resistant strains of TB becoming more and more common.



Social Life

Friday night we played some mean games of squash, ate at the Indian restaurant, and then watched “So I Married An Axe Murderer”. Saturday was spent at a funeral for one of our clinic’s translators that unexpectedly passed away a few weeks ago. We took what can truly be called an expedition, out to the village where the burial was. Down roads that should never have been traveled in a sedan, a one combi (mini bus) and 4 car caravan inched along for several hours to reach the burial site. Though Christian based, very sad, and held under a tarp, the ceremony was mostly different from the ones I’d been to in the US. Many of the speakers were very animated, with some shouting praises at the tops of their lungs while pacing in front of the crowd. The singing was better, mixed with rooster calls and dogs barking; and there were more cows and geese walking around. The wind was at times overwhelming, and it brought a red dust that covered the funeral goers’ clothes and caused them to cover their faces with colorful scarves and tissue. I had an image that the gusts were whisking her spirit away from these clumsy earthly shackles, bringing it back to the greater Spirit from where it came. It was a full 12 hour trek, and though really tired at the end of it all, we felt closer to the staff – and to life.

Saturday night was the 2007 Maseru “Beer Fest”. I use quotations here, as what my expectations held it to be and what in reality it turned out to be were two very, very different things. To preface why I was so deeply crestfallen, my last beer fest (no quotations) was held in Santa Rosa, California. It brought representatives from some of the best microbreweries of Northern California and Oregon. In addition to one of God’s finest creations – Damnation, a golden Belgian-style ale brewed and served in Santa Rosa’s Russian River Brewery (the living room), the selection included Brother Thelonius from Fort Bragg, Boont Amber from Boonville, and a delicious blueberry ale from the Bay Area, to name just a few (I’m beginning to salivate). The entrance fee bought you all the draft beer you could drink, in addition to gourmet cheeses, organic foods and Trader Joe’s peanut butter filled pretzel pockets (yum). The Maseru “Beer Fest” entrance fee bought you, in comparison, all-you-could-eat sausage, rather old appearing deli meats, pretzels made in the 1980s and all the bad Southern African bottled beer you could buy. The night did have its high points, as I introduced jowling (http://www.jowlers.com/ - search for pierce) to a British soccer player and some of the Clinton Foundation workers. See attached pictures.

Until next week,