Monday, September 24, 2007
Sick patients, the Mohale's Hoek and Jowling
September 17 - September 23
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.
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,