The Second Week

Sunday, August 26, 2007

It’s Sunday night, and we’re finishing up our 2nd week here in Maseru. I’m settling in more, and I feel more at home in this new land. I catch myself, as I look out my back yard into Lesotho and a little further away into South Africa, and say – wow, I’m living in Africa. It’s somewhat strange that I have to remind myself. I often feel that this is just another trip during residency – another elective where I’ll learn a little more about developing world medicine, see some cool sites, meet some hard working people, develop a brief bout of dysentery, and then jump on a plane after a month or so and get back to work in the States. But this time is different. I've signed up for the long haul, and it’s just really starting to sink in. In many ways, this experience is very much like residency. We are a small cohort of co-workers, many of which are new and not knowing exactly what to expect. We’re seeing things that we’ve read about but mostly have never seen before. We have new responsibilities, and we’re inundated with new terms, paperwork, rules, and expectations.

Clinic
Last week we (the seven new PAC docs) sat for lectures given by the veteran PAC docs and local staff (nutritionist, social worker, clinic director, etc.) and also saw patients. One of the returning docs is Tony Garcia-Prats. He is the oldest of 10 brothers, son of a neonatalogist and a graduate of Baylor College of Medicine, where he went to medical school, did his pediatric training, and then did an extra year as chief resident. He is a very good teacher and a great guy. He and his wife (Rachel, a biostatistician) have signed on for an additional 2 years in Lesotho. The patient visits are amazing - amazingly interesting, challenging, and while often very sad, also inspiring (Disclaimer: while writing about patients’ stories I will alter and omit details in order to protect their privacy. I tell their stories not for shock value, but to communicate their struggles so that those who learn of them may be better aware of their plight and be better equipped to aid them). One visit involved a woman in her 30s who had given birth to 6 children. Three of her children had died of unclear reasons (sadly this is not uncommon; child mortality is very high in many sub-Saharan countries). She was in clinic with her youngest, an 8 month old child on triple drug HIV therapy (life saving but toxic therapy, needing daily or twice daily, constant and exact, dosing), also taking multivitamins, iron supplementation, and some cough syrup for a “cold” that had lasted for 2 weeks. Like most children in most countries outside of the US, he had received a BCG (Bacille – Calmette Guarin) vaccine at birth to prevent severe types of tuberculosis infection (meningitis and disseminated, or miliary, TB). BCG is a live but weakened mycobacterium similar to TB that makes the immune system think that it’s been infected with TB, so that the body will be more prepared to fight TB in case of infection. As is seen in some immunocompromised children after receiving the vaccine, he developed a BCG infection at the vaccine site on his arm. The infection and inflammatory reaction spread to a lymph node in his axilla, which swelled and burst, leaking pus (unpleasant). Fortunately it was already starting to heal by the day of his clinic visit, and we prescribed no new medicines (pleasant), though sometimes treatment with anti-TB drugs is necessary. His “cold” was most likely an infection of his lungs (pneumonia), so we started him on antibiotics (high dose amoxicillin in this case, though we have no idea of the resistance patterns to amox in Lesotho; but of note the first reports of beta-lactam resistant pneumococcus in the '70s came out of South Africa; perhaps low dose would have been sufficient). He was also quite anemic (less than the normal amount of red blood cells in his circulation). He had been “dewormed” with anti-parasite medications in the last 6 months (a nice image; infections with parasitic worms, especially hookworm, but others as well, are a significant cause of anemia in the developing world), so that base was already covered. He was also on a multivitamin and iron, as mentioned above, to help correct some of the anemia. One of his 3 HIV meds was zidovudine (AZT), a good HIV drug but unfortunately a medicine that causes anemia in many of the patients taking it, sometimes to the point where emergency blood transfusion is necessary. There is no antidote to the anemia caused by AZT; when the hemoglobin gets below 8, patients are switched off of AZT and onto another nucleoside inhibitor, usually d4T (stavudine). The patient’s mother was not sexually active, as her husband, who had never been tested for HIV was afraid that he might get HIV from her (sad and ironic, since he is most likely the source of her infection). Even though not sexually active, she requested injectable birth control, since she did not want to have another baby in the event that she was sexually assaulted. As highlighted by this example, HIV and TB, while often called infections of the poor, are more accurately described as infections of the powerless (and marginalized). Fortunately, there is a center for abused women and children in Maseru, and I intend to learn more about it.
The pathology at the clinic is truly amazing. While in residency, my typical day in the clinic (assuming no Cambodian patients) would look something like: 68 y.o. man with hypertension, diabetes, obesity, and hypercholesterolemia; pregnant woman with heartburn; 8 y.o. well-child visit for vaccines, newborn baby check up, 28 y.o. woman for well-woman exam, etc. The few visits I’ve attended here were, in addition to the above mentioned case, a 2 yr old who weighed what a 9 month old would weigh in the States, a toddler with active pulmonary TB, a 5 year old that only says 2 words due to the effect HIV has had on his brain (HIV encephalopathy) – he is about the size of a 2 year old, and his mom almost died in the hospital earlier this year, and an infant with oral thrush that looked like a skeleton due to acute and chronic malnutrition and dehydration (skin tenting, sunken eyes, etc). Patients, like this infant, that would be managed in the hospital and intensive care unit are often managed as outpatients due to necessity. Part of this is because at the local hospital: there is no pediatric or neonatal ICU, at night there is 1 nurse for about 30 patients, there are no residents (though some sort of medical officers due cover the wards), the attending physicians are few and far between, there are deaths most every night, and so forth. I can barely imagine what it’s like in the more tropical countries with similar health budgets but that are also ravaged by additional scourges such as malaria, schistosomiasis, and dengue. To its credit, the hospital has imaging available: x-ray, a CT scan (albeit old, works intermittently, and it gives off more radiation than modern ones do), and an ultrasound. It also has lab facilities (CBC, electrolytes, BUN/Cr, HBsAg, CD4, HIV EIA (no viral load) , transaminases, and limited microbiology) that might even come back the same day if you get the blood there before noon, M-Th.
In addition to the work in the clinic in Maseru and rotating through the hospital, we’ll be going to rural sites throughout the country. I’ve been assigned to Mokhotlong, what I hear is a beautiful town in the mountains near the famous Draakensburg (Dragons Mountains). Around 5 hrs by car or 45 minutes by small prop plane, it’s one of the sites where we’re upscaling pediatric HIV care and prevention of mother to child transmission of HIV. I’ll spend a few days to a week in Mokhotlong every few weeks – consulting, teaching, and generally just helping out. This is supposedly the “real” Lesotho – up in the mountains and the snow, surrounded by amazing vistas, treating the sheep herders and their families, and preventing more babies from being born HIV positive in the Kingdom in the Sky. Romantic, huh? In reality I’ll probably be freezing my nalgas off under a mohair blanket, wishing for fast internet and mocha chai fat free latte cappuccino. We’ll see – first trip is in October.

Donations
A few of you have asked how you can help. No need to give anything. But if you really want to, all forms of support are welcome, from meditations, prayers, letters, toys, visits, and monetary donations. Our main clinic in Maseru is surprisingly well funded. Nonetheless, there is a list of necessary items: certain meds and equipment are lacking at our main clinic and the many clinics and hospitals that we work at throughout the country. Also, there is a transportation fund for those patients that cannot afford the one to four dollar fee to get to and from clinic. Send me an email and I can check in with our clinic director about how best to handle your donation. I would like to thank Dr. Allison Froese, skillful and compassionate Canadian anesthesiologist and teacher who donated a wonderful laryngoscope and blades to the clinic (while there is currently no working respirator in the clinic or hospital, a child was intubated in the clinic for respiratory failure most likely due to home overdose of seizure medications and was bag ventilated in the back of an SUV during the hour long overland international transfer to Bloemfontaine, South Africa).

Social events
Went to a birthday party for one of the clinic sub-directors the other night. The food was excellent – northern Indian cuisine with great veggie options and relatively few parasites. The company was even better. The 30 or so guests were made up of Baylor AIDS corps docs, Partners In Health workers (Paul Farmer was not present, though it was great to meet these guys that are working both in very rural sites with HIV and multi-drug resistant TB and in the capital building our first TB lab able to run cultures and sensitivies, improving treatment of MDRTB/XDRTB; Lesotho is one of the top 3 countries in the world for prevalence of HIV/TB co-infection), and Clinton Foundation staff (they are mostly public health and business trained people that procure affordable HIV drugs in resource poor settings). How inspiring and humbling to be surrounded by people doing so much for people with so little.

Closing
OK, so the length of these entries is a little insane. See what happens when there are no microbreweries in town? Way too much free time. Thanks for making it to the end. Miss and love you guys lots.