Monday, September 24, 2007

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,


Sunday, September 16, 2007

Blood Sick Doctor

September 10 – September 16

Hello, and welcome to my blog. A big thanks to Cindy Su and Bruce Heller for convincing me to stop sending out group emails and finally setting up a blog. I’ve up-loaded the old emails as well and added a few pictures. Enjoy!



Clinic

On Wednesday I was “blood sick doctor”, the rather ominous sounding title for the doc who is in charge of reviewing the labs (“blood”) and being available to manage the “sick” kids that come in the door. Now, some would say that all of the patients at an HIV clinic in southern Africa are sick, but really most are fairly healthy. Granted, they might have pulmonary tuberculosis, pelvic inflammatory disease or strep throat, but they’re walking in by themselves and can usually walk out just as fine after a routine clinic visit. The sick visits are the kids that are decompensating and need stabilization before sending them out for them to return to the clinic the next day or for admission to Queen Elizabeth 2 hospital (QE2). These are the ones who need oxygen due to asthma attacks or bad LIP (lymphocytic interstitial pneumonitis), the kids that are acutely dehydrated and need ORS (oral rehydration solution), or as was the case on Wednesday, the ones with pneumonia, severe malnutrition, bulging fontanelles and 4 days worth of seizing. First was an adolescent with cough, fever, fatigue – hopefully just a community acquired pneumonia, I chose high dose amoxicillin and clarithromycin and told them to follow up before the weekend if she wasn’t doing better. Next came the infant with severe malnutrition, regional BCG disease (swollen vaccine site on the arm and a large ipsilateral axillary node), and a bulging fontanelle. We performed a lumbar puncture, gave antibiotics for possible meningitis, started TB treatment, ordered a chest x-ray, worked on the refeeding schedule and (you might be guessing “admitted the child”) sent the child home to follow up in 2 days. Last was the real sick child. Another infant, this one had been seizing for 4 days and was finally referred to us from a community clinic. A rectal dose of diazepam, though paraldehyde (yes! From MUDPILES) was also considered, calmed the seizures initially. We performed another LP and this time the fluid looked like someone had spit a loogie (lugie?) into the test tube. I have never seen frank pus slowly ooze out during a tap until today. We did a quick gram stain on a drop of the CSF, looked at it under the microscope and saw tons of white blood cells and gram positive diplococci in pairs – most likely Streptococcus pneumonia causing the meningitis. Unfortunately there is no pneumococcal (nor H.flu) vaccination program in Lesotho. As the child had begun seizing again, we dropped a nasogastric tube, loaded him with Phenobarbital, and admitted him to QE2 for intravenous antibiotic treatment with high dose ampicillin (100 mg/kg Q 6 hours) and once a day gentamycin (7.5 mg/kg/day). His prognosis is not good.




Social Life

Baylor vs SOS orphanage

This Friday our clinic took on our neighboring orphanage (not the orphans, but their adult staff) in a fierce (not really) football (soccer) match. Basically, the Baylor team is made up of the local staff (cleaners, guards, translators, drivers) that rock and the white doctors (sorry Anu) that suck, with the exception of Tony, one of the returning PAC docs. I have never played soccer, except when I would get my butt kicked once a year by the small barefoot boys in the Honduran village where Baylor has been building a clinic. I have no skills with my feet. None. Granted, I am able to run quickly from one end of the field to the other, but it’s mostly pointless since none of the locals purposely pass me the ball. Nonetheless, we tied, and we had more fun, too. The women from the clinic sang songs throughout the match and would flood onto the field when we scored. Now all I have to do is get them into Ultimate Frisbee…
T-Y

Saturday we took a day trip to Teyateyaneng, or T-Y for those of us that can’t pronounce it. It’s famous for its hand woven tapestries and rugs. I took some pics of some of the good ones. Aside from a brief near death experience when we were accidentally driving on the wrong side of the road, we had a great time.


Basotho Hat

Sunday morning started with an amazing brunch at Seema and Guada’s house – pancakes (with the much coveted real maple syrup – hand delivered from North America), quiche, fruit salad (guava, papaya, kiwi, strawberry), and banana bread, among other things. The table was full – PAC docs, Nick (a visiting med/peds resident from Houston), and Djin-ye (a med school graduate from Berlin). A quick trip after brunch to QE2 showed that the infant with meningitis was still alive, then off to hike up the mountain where the past kings and royal family are buried. The hike was great – a cool breeze accompanied us up a hill with some good rock climbing (left my climbing shoes and chalk bag in my closet), free roaming horses, scrambling lizards and expansive views of mesas and plains dotted with evergreens and cacti. We saw the famous conical hill where one of the early past rulers hid from his enemies. The shape of the hill then became the design for the unique basotho hats that many of the locals wear and is one of the main cultural icons for the kingdom. Hope all are well. Let me know what you think of the blog; until next time –

Friday, September 14, 2007

Queen 2 to Bloem

September 3 – September 9

Clinic
The pace is picking up a little in clinic as I get used to the clinic routine. I’m getting accustomed to the electronic medical record, the referral forms, the questions I need to ask, and even picking out some of the Sesotho phrases I hear the patients use like, “why is that white doctor so hairy?” (though still don’t know when the official language lesions are going to start). I’m getting a little more comfortable with managing the 3 year old HIV positive child on active anti-tuberculosis treatment who presents with moderate wasting (acute malnutrition). Just a little more comfortable. Almost every day I see a patient that has a dermatologic finding that could be placed in a dermatology atlas. We actually have this great teledermatology resource. We take a photo, include the patient’s history, send it to a dermatologist/dermatopathologist in Philadelphia with specialty training in tropical medicine who then emails us back her opinion. Very nice. She even accepts biopsies that we DHL to the States. So far I have taken pics of (what I think are): a pyogenic granuloma on a pregnant woman’s cheek; oral hairy leukoplakia of the lateral tongue, widespread flat warts around the face and neck of an adolescent, nail discoloration possibly due to AZT, chronic, widespread molluscum contagiosum, and some sort of benign mucosal hypermelanosis. I’ve also seen what’s most likely inguinal adenopathy from lymphogranuloma venereum, scrofula, a fair amount of herpes and possibly some secondary syphilis and PID.

Queen Elizabeth 2 Hospital
I went to QE2 on Friday and was reminded that I was in Africa. This public hospital truly has a major lack of funding. It makes my “old” community hospital from residency look like the Westin. Plaster was falling off the walls and ceiling, you have to dodge holes in the floor, you try to ignore the occasional many-legged critter on the wall, and LPs are done without iodine, sterile gloves or spinal needles when supplies are out, to name a few of the specifics. The “pediatric ICU” is a small room with one oxygen concentrator (not an oxygen tank, but a machine that can concentrate the room’s oxygen and deliver it up to about 5 L/min) that has 3 to 6 tubes snaking off it in a jumble of tubing in the middle of the floor, each going to a different patient sharing what little oxygen the machine can produce (sometimes you can't even feel the flow of oxygen on your hand; unsure if any reaches the alveoli). There might be a 6 week old sharing a crib with a 4 month old, next to a bed with a 9 year old, all with different ailments, many of which are likely passed fairly freely between them (“here, try my infection; ok, now I’ll try yours”). There is one dedicated pediatrician on the ward (Dr. Phiri, a Malawian woman who has been working there for decades) and about 3 medical officers – people that have graduated from medical school but seem to be stuck, thanks to a lack of funds that would allow them to go out of country to a regular residency, in an odd permanent internship with no lectures, no hope for advancement, and no Thursday group sharing sessions. But damn, can they find a vein. All of their training is on the wards, and they have to start all their IVs, draw all their blood, do the LPs, drop the nasogastric tubes, deliver the specimens, etc. The nurses’ sole responsibility is to give medications (we prescibe Qday dosing whenever possible). There is no phlebotomy, nurses don’t give food (parents feed their kids, but unlike poorer hospitals, they at least don’t have to cook the food as there is a kitchen), people don’t come to pick your patient up and take them to radiology, and there are no Wellness Dogs (though I did find a woman with a monkey in her hair, but that was at a restaurant in South Africa). We see the HIV positive kids that are admitted from our clinic. These are very sick kids, as even the pretty sick kids we try to manage as outpatients since the mortality is so high in the hospital (no attendings or residents in the hospital after hours, and sporadically on weekends). We’ve recently had sort of a neuro service: a 7 month old with severe wasting, dehydration, and likely meningitis with a blown pupil but flat fontanelle, a ~9 month old with possible idiopathic intracranial hypertension (pseudotumor cerebri from…?hypervitaminosis A, iron deficiency anemia, HIV itself?), an adolescent with likely viral encephalitis that growls, kicks, and occasionally goes AWAL, and a toddler with brain lesions of uncertain etiology, subsequent hydrocephalus and Cheyne-Stokes breathing, seizures, and possibly temperature disregulation due to the CNS damage. They are all managed by, that’s right, us. That’s not to say that we manage them exceptionally well; we do what we can. No quick calls to Dr. Warner to manage the case for us, no going down to chat with the neuroradiologist about the differential. Thankfully, the internet really helps, and I’ve written some emails and sent some pictures of CXRs and CTs to friends in the US.

Social
Took a good trip to Bloemfontain, a city of 500,000 in South Africa about 1.5 hrs away from Lesotho. We found hearty food and drink, soft-serve ice cream, and The Simpsons Movie (only 2 bucks!) all at a cheesy waterfront mall. Really made me feel like I was back home. Went for a great run up a big hill near the house. After the chest and jaw pressure subsided I noticed that there was a great, nearly panoramic view of Maseru up at the top. Bright, clear blue skies and 70 degree weather – so this is Africa.

Week In Review

August 27 – September 2

CLINIC

Seeing patients and PMTCT:
We (the new PAC docs) have started seeing patients fully on our own now, with help from our friendly translators (some of which are openly HIV positive and are community activists). The oversight and teaching is great – I can stick my head out an exam room door, pull aside one of the “veteran” PAC docs and ask questions like, “Do you think this is TB or pneumonia”. We also have lectures during the week. It’s amazingly like residency, or perhaps more accurately like a fellowship in HIV in Africa. I’m seeing somewhere around 50% peds and 50% adult women in the main clinic in Maseru. Many are relatively healthy, doing well on their HIV meds with few complications. Many are stunted (short stature due to chronic malnutrition), and some are wasted (acute weight loss associated with sudden illness). There are a few adult male patients in the clinic, but most of them go to the adult HIV clinics in town, including the HIV center down the road. That clinic is called Senkatana, named after the legendary hero that slayed the giant monster that was eating up all the people of Lesotho. It’s a nice metaphor for the country’s attempts to conquer HIV. Mike Tolle, Texas trained family physician and all around great guy, has just finished his year as a Lesotho PAC doctor and has started working in the department of retrovirology in Houston. Along with the internist in the group, Matt Gralewski, they had been doing the brunt of the antenatal clinic work for the clinic. It’s a little daunting being the only formally trained family doctor in the group. Matt is great and has been teaching me a lot about the prevention of maternal to child transmission of HIV (PMTCT). We concentrate more on HIV care than basic antenatal care, though we do perform some basics. We have this great “portable” Doppler machine to hear the fetal heart beat. It weighs about 20 pounds and is made of what looks like metal from a WWII tank, but it works alright. I’ve also been using a metal cone to find the heart beat when the machine isn’t around. When the room is very quiet and the pregnancy is fairly far along, you can actually hear the heartbeat decently well. If anyone has a somewhat more portable Doppler that could use a new home, let me know. Like many parts of the developing world, Lesotho has a long way to go with PMTCT. In the States, just about every HIV positive woman is placed on at least 3 HIV drugs, known as highly active anti-retroviral therapy (HAART), every day for most of her pregnancy in order to prevent the baby from becoming HIV positive. In a non-breastfeeding woman/baby pair, this means that women on HAART pass the infection less than 2% of the time, as compared to 25% of the time without any medications. In very poor areas of the world, where women don’t have access to HAART due to a combination of lack of expertise, funds, and infrastructure, the most basic PMTCT prevention involves a single oral dose of nevirapine (NVP or Viramune) to the mother and a single dose to the newborn infant. This reduces the transmission to about 12%, again in a non-breast feeding couplet. As simple as giving one drug to mom and baby that would cut the rate of HIV transmission in half, only about 5% of women in Lesotho get this. There are about 50,000 deliveries a year in Lesotho, where more than 1 in 4 of the women are HIV positive; and the rate of transmission from mom to baby is about 40% without treatment. Without PMTCT about 5,400 children are born HIV positive. Without pediatric care of HIV positive kids, about 30% of these children die by 1 year of age and 50% are dead by age 2. We have some work to do. We are scaling up the PMTCT, with the following goals:
Most pregnant women get the WHO recommended regimen for pregnant women in resource poor settings, which involves a few drugs and cuts transmission to about 6% (18% if breastfeeding).
Those women that have more advanced disease get HAART, just like the women in US and other resource rich settings, cutting the transmission to about 2% (around 8% if breastfeeding).
At the very least, when the above two goals cannot be met, all women get at minimum the single dose NVP.
Breastfeeding is another huge topic that I won’t get into now except to say the following. Breastfeeding is not recommended for HIV positive moms in the US since HIV is passed in breast milk. Breastfeeding is recommended in many parts of the developing world for HIV positive moms because formula often is not accessible, feasible, affordable, safe and sustainable. A significant proportion of children in such settings die of diarrhea and malnutrition when they are on formula instead of breast milk.

SOCIAL LIFE

Live music in Lesotho and 5 Legged Cows
During the week we went to the local fancy hotel the Lesotho Sun to hear No Jazz, a group of young musicians from France on their African tour. The event was hosted by the Aliance Francais (something like that). Though there were no French fries or French bread to be found, we did enjoy some progressive French “jazz” – an interesting mixture of rap, spoken word, and synthesizer in addition to the more traditional sax, trumpet, keyboard and drum set. For the whopping entry fee of 90 Maloti ($12 US dollars) we enjoyed one free drink on the house and the chance to rub elbows with the Lesotho elite. Friday night was a going away party for some of the Partners In Health workers (working with HIV and drug resistant TB) where I met a Frenchman who had never heard of Zinfandel (“Wat ees dees Zeen that you speak of?”). Shocking; I suppose Zin is more of an American thing. Saturday night brought a house party at one of the Clinton Foundation worker’s houses, complete with wine and cheese, vodka soaked fruit and Jello shots (yes, Jello shots). Afterwards we went to Good Times CafĂ© where we danced to the vibrant jams of a local band headed by a great Masuto female vocalist. Sunday morning we went to our first Hash. This international organization is a slightly strange, fraternity-like gathering of ex-pats who hike once a week, chant rhymes and enjoy a beer after the hike. Just a little drive towards the outskirts of Maseru, the hike brought us some of our first views of the “real Lesotho”: winter tan and brown plateaus and montains with smatterings of the spring pink peach tree blossoms, roving sheep and cattle herders and a five-legged cow. Yes. That’s right. At the end of the hike we came upon a calf with a fifth, fairly small and most likely unhelpful, leg growing off of its neck. Cow manure, you say. But really; we have pictures.

Cheers,

Jeff

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.

Adjusting


8/21/07

A week has now passed since arriving in Africa. Since that last communication, life in Lesotho, the Kingdom In The Sky, continues to be good and bring interesting little adventures. Here is a re-cap of what’s been going on.

The Living Situation
Anu (friend from med school, recent Oakland pediatrics grad) and I have moved out of the “Baylor cottage” located on the clinic grounds. We miss getting the free wi-fi internet access from the clinic but enjoy being closer to the center of town and having our own place. We finally were able to unpack that first night after leaving the cottage, mostly to keep warm by constantly moving; the 3 space heaters we had enjoyed in the cottage (including Big Bertha, which is more like a super nova than a space heater) didn’t come with us, and our new house had none. The beauty of 30 degree evenings quickly wanes with no central heating and no space heaters. We did manage to collect some brush and build a fire in the fireplace (I know, why am I complaining?), and that did warm up the place. Our 3rd roomie, Kara Dubray (recent Oakland pedi grad), didn’t make it in that night as expected, and with no phone, we weren’t so sure as to why. Early next morning I had a vague sense of someone repeatedly leaning on their car horn. After I cleaned out the icicles and tundra moss that had grown in my ears during the evening chill, I realized that Kara had simply missed her connection and arrived the next morning instead. The house has a “guard”, Isaac, who is a tall Basuto young man of 29 yrs. It’s mandatory that we keep him, per BIPAI, and I suppose it’s a good thing to help give another local a living. His official watch is from 6 pm to 6 am. He speaks a little English, we speak a little Sesotho; basically we have no idea what the other person is saying. The best we can figure out, his routine involves talking over the fence to the next door neighbor’s guard in the early evening, then around 730 pm he retires to a side room, wraps up in his customary Basotho blanket, turns on the heater, and falls asleep. Usually, when a guest honks their horn outside, we are able to beat him to the gate (“Yay, I won again”). He does enjoy the food we bring him (Anu is impressed how he is able to wake up with just a tap on his door when you have a plate of food in your hand). The house is pimpin’, if you will, with a great stoop (porch) for stoopin’, which involves sitting on the stoop and drinking beer and or wine. There is a eucalyptus tree, sans koala, a fenced off “garden” that currently resembles two elephant-sized graves, a walk in vault (some previous owners “sold jewelry” we’re told) but currently is just a closet (safest shirts and underwear in all of Lesotho), and all the amenities that you’d expect in a house in the US. No hot tub, but I’ll work on that. Our kitchen is stocked with good foods (peanuts, cereal, cheese, beans, and beer – mostly unchanged from my kitchen in Santa Rosa). Anu likes to cook, so we have chutney, pasta…even veggie burgers. We found out the hard way, tonight no less, that the box on the wall with digital numbers (that count down, though we hadn’t noticed this small but important detail before tonight) tells us how much electricity we have left. Much like a calling card, you add minutes to it at the electricity shop. We came home tonight from soccer to find that we were out of minutes (we were really out this morning; we just thought it was a power outage). Bummer. Thankfully the food in the fridge doesn’t spoil in arctic weather, so the goods were, well, still good. As the Basuto government realizes that most foreigners are ignorant to buying electricity minutes, the store is open 24 hrs for just such occurrences. So with help from the clinic sub-director (after she stopped laughing), we figured out what went wrong and were back in business.

The Gym
So some of you might have already heard about The Gym in Maseru. Nicer than most private gyms in the States, and certainly nicer than the government hospital across the way from it, the Gym looks like it was built on another planet and landed by mistake in this small African country. We signed up for the Gold Membership the other day. For a whopping 19 US dollars a month, you get weights, heated pools, treadmills, bikes, elliptical machines, rowing, squash courts, ping-pong (YES!! - oops, no nets), etc. We passed up the Executive Membership which adds the dry sauna and steam room. As much as I enjoy these normally, we decided that in a country with one of the highest rates of tuberculosis and enough extensively drug resistant TB to attract Paul Farmer’s Partners in Health group to start a project here, it’s best to avoid cramped, small, damp, enclosed spaces filled with near-naked Basuto men coughing into your alveoli. We also saved 5 dollars a month with that decision. Learned to play squash (like racquetball but with a ball that looks like it should bounce but doesn’t; the game is named after the noise that’s made as you run into the plexiglass wall at the back of the court). The Basuto male members are all large. That is, the men that go to the gym are built like tug boats. I doubt that any of them are traditional sheep herders; if they are they must carry their sheep from town to town.

Work
Most of the days this week have been spent filling out paper work. Proof that I am a doctor, proof that I haven’t been arrested, questions about my plans for work in Lesotho, questions about how many wives I am bringing into the country (I need special permission from the government for more than one!). We’re getting to know the ropes around the clinic through lectures and a little shadowing. The clinic is new and nice. Yes, the rumors are true – the medical records are electronic, typed during the clinic visit on these box-machines called “computers”, for my friends at the Santa Rosa Family Practice Clinic. Believe it or not, we have social workers, in-clinic pharmacist and pharm techs (that can compound meds, do pill counts, alert us if they think there are adherence issues), nurses that go into the community to find patients that have missed appointments, real, live, translators whose job is to translate (instead of also be a nurse or clerk, and no freaking AT&T translator phones), a classroom for lectures (with built in computer and projector hardware), wireless internet (fast), dial up internet (slow), a small library, local artwork, a lunch room, etc. Clinic starts around 830 am. The day begins with the staff and some patients singing harmonized hymns (they’re amazing; I’m making some recordings on my iPod and will send some soon). Some of the kids come in very sick and have to be coded in the treatment room. Most look and are relatively healthy. Many of the kids around this clinic that need to be on antiretroviral medications are on them. The waiting room is crowded but not pandemonium. The patients come en mass in the early morning without individual appointment times and are seen in the order they are registered, except for those discovered on triage that are very sick. There is “Family Clinic” which means adults, 90% of which are women, lots that are pregnant. We provide the prevention of mother to child transmission care to the pregnant women, prescribing and managing their meds, etc. They continue with their midwives/obstetricians for routine antenatal care and deliver either at home or at the hospital with those same providers. Perhaps unsurprising to some of you, I’ve started to see what opportunities there are to get involved with actually catching the little wet willies when they’re born. We’ll see. Otherwise, work looks like it will be divided between the main Baylor Center of Excellence (COE) in Maseru, the run down government hospital wards at Queen Elizabeth 2 (aka QE2, or Queen 2), QE2’s own pediatric HIV clinic, and then work outside of the city. This community work sounds great - road trips or small plane trips to the mountains, past mesas and waterfalls, to set up pediatric HIV clinics in hard to reach areas around the country. Teaching opportunities abound, from training med students and residents from the US that rotate through Maseru, to lecturing to doctors and nurses in India about pedi HIV care, and lots in between. Of note, I haven’t yet found a group, whether government or a non-governmental agency (NGO), that is actively working with the sex workers in HIV prevention and treatment. With the successes seen in places like Thailand and India, I would be surprised if a program has not been implemented to help with this marginalized and stigmatized group. More on this as it develops.

That’s all for now. Hope you are well. Keep those emails coming.

In The Beginning

8/14/07

Greetings and salutations. Welcome to the beginning of (and longest entry to) my internet journal of my travels in Africa with the Baylor International Pediatric AIDS Initiative (BIPAI), as part of the Pediatric AIDS Corps (PAC). I am currently a few thousand feet in the air, above what is either Botswana or northern South Africa. We’re too far up, so while I can see the browns and greys of an arid landscape below, I have to squint my eyes and fire up my imagination to see the herds of cape buffalo and zebra. My long time friend Anu Agrawal, who I’ve known since medical school and has recently graduated from the Children’s Hospital of Oakland pediatrics residency and joined the PAC, is sitting a few rows ahead of me, possibly reading, sleeping, or watching the Disney cartoons that are showing on the plane’s teleprompters (the sun has just risen on the 2nd of two red eye flights we’ve taken in the last 40 hrs). We’re nearing the end of a long trip that started in the morning of 8/12/04.

Graduation and travel home
To take a few steps farther back, I graduated from family medicine residency on July 1st, with a beautiful ceremony at the Trentadue winery in northern California, attended by the Pierce clan. After packing up and saying goodbye with a heavy heart to my friends, the Russian River Brewery, and the hot tub, my brother David and I squeezed into the Element (The Toaster) and made a 3 day journey to Texas. With scenic views, including Route 66 and the Grand Canyon, we made it home without any mishaps (and somehow still as friends). After a week in Corpus Christi, catching up with my family, I packed up again and drove to Houston to begin the PAC pre-service training.

The PAC is composed of about 50 doctors, mostly pediatricians, but also including medicine/pediatric doctors, family doctors and and a few internists. Many of us have just graduated from residency, a few have recently completed fellowships in hematology/oncology, cardiology, or masters of public health, and some have been out in practice for a number of years. The PAC’s mission is to provide quality, compassionate care to children and their families affected by HIV/AIDS in Africa. It begun only last year, as a way to staff the clinics that have been built through BIPAI in the African countries of Botswana, Lesotho, Swaziland, Malawi, Burkina Faso, Uganda, Tanzania, and most recently Kenya (I have a feeling that sites on the horizon are Namibia and Mozambique). Funding for the clinics and for the PAC is through a combination of contributions from the local African governments, Baylor College of Medicine (BCM), and the philanthropic branch of Bristol-Meyers Squibb, among others. Of the 52 docs that were placed on the ground last year, around 30 are staying for a second year and that means there are around 20-24 of us newly assigned PAC docs this year.

Wednesday, August 15, 2007

I’ve now safely arrived in Maseru, the capital of Lesotho, and am writing on my laptop in bed while accessing the wireless internet from the clinic across the yard. Before elaborating on that, I’ll catch up a little on how I got here.

Houston
The training in Houston, which began 2 weeks after residency graduation, went well. They put the 2 dozen of us up in the relatively fancy Marriott Resident Inn in downtown Houston. Ahh, Houston. I had forgotten all the wonderful things it boasts: barbeque, roaches the size of small mangoes, 100% humidity, 90 degree weather, aggressive homeless folks, traffic, hmmm, what am I leaving out? OK, to be honest, I loved getting back to my favorite haunts – the Gingerman (great bar) and Rice Village, Istanbul Grill, Balaji Bhavan (south Indian cuisine) and seeing some old friends. The first weekend brought my family medicine boards (2 more weeks till I get my results...). Monday through Friday we sat in lecture, mostly covering HIV, TB, and tropical disease. We worked in small groups on case assignments, did a little lab time, and filled out a ton of paperwork necessary for working and living abroad (taxes, insurance, shipping, loan repayment, canceling your cell phone, arrangements with your bank and car insurance, etc). It’s amazing how much stuff is involved. The prime minister of Lesotho dropped by Houston on his way from speaking with Bush about HIV in Lesotho. We had a fancy lunch with him, part of his cabinet, and lots of serious looking buff guys in suits with ear pieces. I got to speak briefly before him and the delegation about how excited we all were to get started in Africa. The local NPR was there and did a little story on it. (http://www.kuhf.org/site/News2?news_iv_ctrl=1521&page=NewsArticle&id=21102)
The PAC group looks great – compassionate, funny, talented people. I feel very lucky to have the chance to work with them. We bonded quite well during our time in Houston. While we were excited to head off to our respective sites in Africa, it was hard saying good-bye to those that will be many miles away in other sites. We met two other docs that were doing the training with us but that weren’t going to Africa through BIPAI. Katy, a long time pediatric ER physician, has worked for Doctors Without Borders for many years. The other, Jen, has been out of pediatrics residency for only a year but is traveling though Physicians for Peace to Eritrea (near Ethiopia) to help start the country’s very first pediatrics residency.

Germany
I drove back to Corpus for two last nights with the family. They saw me off at Corpus’ little airport, where I flew to Houston and met up with Anu. We took the 10 hour flight to Frankfurt, Germany, where the men are tall and the women are taller. Wow, there is a plethora of attractive, beer guzzling women that would make quick work of me if I cut in front of them at the line to the bar. One of my first sights at the Frankfurt airport was a large group of Orthodox Jews in full regalia, bobbing while praying and facing one of the walls in the terminal. It took me a second, but I realized how wonderful it was to experience what was impossible to see only 60 years ago.

Maseru, Lesotho
So since most people will have given up reading by this point, I will keep this short for you die-hards. We arrived in Johannesburg (Joburg, as is hip to say; you’ll look, sort of, like a local, if you do this) without trouble and rushed through customs, grabbing my baggage and getting into the tiny terminal for those going to Lesotho. This plane was a little puddle jumper, room for about 30-40 small legged people and one short (required) stewardess. We stepped out of the plane around noon and were greeted with amazing, very non-Houston like weather – mid 50s, sunny, clear and crisp. The landscape is gorgeous, like a mixture of Joshua Tree National Park, Arizona and New Mexico. We’re in the end of winter here, with most days in the 50s and nights in the 30s (tonight the expected low is 18F). One PAC guy that’s been here a year complained to us that it wasn’t overcast and rainy enough for him. After wintering in Santa Rosa, I’m ready for some dry winter days. We were greeted by Dr. Edith Mohapi, the clinic director whose husband is the Minister of Finance (nice people to have in your cell phone for emergencies). Driving on the left side of the street in a car with the steering wheel on the right (wrong) side and the shift on the left (wrong) side is a little weird, but I think I’ll get used to it. We’re temporarily staying in the “cottage”, the living quarters built on the clinic campus for visiting docs and med students. Cindy, Kevin, Dewey and any others who had the pleasure of staying at the Casitas Verdes at the Hospitalito Atitlan in Guate will see no relationship between them. Steaming hot water shower, fridge, washer/dryer, wireless internet, and a distinct absence of scorpions are some of the stark differences. Man, am I in Africa?

I already miss you guys very much. I do hope that I can convince someone to come out this year, though I know how busy it is, whether working the daily grind or getting through residency. It looks like I can entertain visitors whenever I want; clinic is M-F, mostly in town but some work in the rural parts of the country, some traveling for teaching seminars and meetings, and 4 weeks of vacation. Additionally, I’ve already started snooping around to see about elective opportunities. According to BIPAI central, most months for the coming year are filled for all PAC countries, but our clinic director says there's probably extra room for those interested. There is a government hospital in town that people occasionally rotate through, though Dr. Mohapi says that it’s understaffed, undersupplied, and you might be asked to do things out of your normal scope of practice. Don’t worry, Jim, I told her right away that I knew a few people that might find that somewhat entertaining. Luckily, there are better ways to get here. There is a direct flight from D.C to Joberg, then it’s just the 1 hr flight to Maseru. I’ll let you guys know more about working here after I actually start to do some myself.

OK, I’m out. Take care. Jake, do me a favor and say hi to the ladies in the clinic (Eugenia would never forgive me if I didn’t).

Jeff