23 oct 2008 - post-mortem

The cottage where I stayed in Maseru, as a visiting physician for a month, is immediately adjacent to the clinic building. As I mentioned before, many patients arrive fairly early in the morning, and the clinic doors open at 7am, though the doctors, the rest of whom live at least a 10 minute drive away, aren't usually there until 7:30am at the earliest.

The last day I worked at the clinic, I woke up at 7am and got into the shower after brushing my teeth and shaving. Shortly after, I heard someone banging frantically on the bathroom window from outside, and I knew immediately what it meant. I jumped out of the shower, put on a pair of jeans and a t-shirt after quickly drying off, grabbed my stethoscope and ran outside, where one of the clinic nurses was still banging on the window.  She saw me, ran over, and breathlessly confirmed what I had suspected -- a very sick patient had just arrived at the clinic.

We ran over and I got to the treatment room just in time to see a pale, cyanotic, three month old infant gasp his last breath. Although my first instinct upon walking in the room was to think (and almost say aloud), 'we need to intubate this kid,' it was not an option. We simply don't have the equipment to do it. There are no ventilators in Lesotho, so as a consequence, nor are there any laryngoscopes or endotracheal tubes. I helped the nurses already there with positive pressure ventilation and chest compressions, but looking at the child I knew from the outset that it would be futile. He had stopped breathing, was pulseless, and we couldn't intubate him.  There was neither IV access nor epinephrine to push.  After about another minute, I did the only thing I could at that point: I called the code. Time of death: 7:24am. 

The infant's mother crumbled to the ground sobbing; one nurse looked sullenly away as another quietly covered the child's face with a white sheet; I stood staring down at the lifeless body, stethoscope dangling over my left shoulder, interlocked hands resting on top of my wet head, and took a deep breath. No one said a word; there were no words to say.

We break the silence by uttering soft reassurances to fill the uncomfortable void, but they are ineffectual, inconsequential. An infant has died, one of several this month. And though we may become desensitized to many things we see with regularity, this cannot be one of them. I stand over the tiny corpse and consider this indisputable demonstration of our limitations, this unmistakable demand for humility, and bow my head.

29 oct 2008 - south african travels

as i'm short on time and bandwidth, i'll have to rely on pictures being worth their reputed thousand words for now.  i'll catch up with the text (admittedly far less interesting than the pictures, let's be honest) later, more for my purposes than anything, mainly to feed my egotism as a closet writer.

in short, though, the mountains left me breathless in semonkong, where i also abseiled down a 204 meter waterfall (the highest commercially operated abseil in the world); the clinic continued to challenge and astound me, though i did feel i made a contribution, learned a tremendous amount, and recognized within myself a sincere desire (and perhaps even a need) to return for a longer period of time; i saw unforgettable numbers of (unforgetting) elephants at addo national park; i hiked many kilometers of rugged coastline and lush forest along the indian ocean in tsitsikamma national park, both intentionally and unintentionally (i.e., i got lost on one of the hiking trails); i went kloofing in wilderness, hiking, swimming, hopping rock to rock, and even jumping off a few cliffs into the river below.

tomorrow will take me to stellenbosch, the heart of south african wine country, and then onwards to capetown for a few days before returning stateside.  feel free to peruse the photos for now, and (who are we kidding) there will probably be more from me later.

much love from south africa,

sachin

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more photos:

high in the mountains in semonkong

elephants galore at addo

rugged coastline besides lush forests in tsitsikamma

kloofing in wilderness

taking in the views in cosmopolitan capetown

15 oct 2008 - resources and resourcefulness

I resumed work at the clinic on Monday, and have found a nice rhythm seeing patients on my own, trying to pull my weight. Most of the patients show up pretty early in morning, having often travelled from long distances to make it to the clinic. They are registered in order of arrival, and after going through whichever combination of pharmacy (for pill counting), triage (for vital signs, height and weight), social work (for adherence counseling), and lab (for blood draws) they had been slotted for from the last visit, are called back by us into a room as we finish with the previous patient. The waiting room is teeming in the morning, and gradually thins out as the day goes on and patients are seen and leave. There are no assigned appointment times, it’s essentially first come, first served.

Working in a country in which I do not speak or understand a lick of the local dialect has been a new experience for me, one that’s required some adjustment. For one, like most of the other PAC doctors, I rely heavily on the translators for my history and counseling. The translators at the clinic are all involved in some way in the care of HIV positive children or are positive themselves, and are remarkably good at what they do. Each one has their own personality, and often will launch off on their own into counseling, scolding, explanations, and exhortations. It’s not unusual for me to ask a simple yes or no question through the translator (e.g., ‘are you breastfeeding?’) and 10 minutes later, after an animated discussion between the patient’s mother and the translator, complete with yelling, arguing, and finally perhaps some laughing, I’ll get a clearly understated answer (e.g., ‘she is now’). And for all the experience, insight, and cultural fluency they have that someone like me could never even approach, it’d be foolish not to trust them and encourage them to take ownership like they do.

That said, I miss the closeness I’d have with the patients if I spoke, even semi-fluently, the language. It’s certainly a skill I could hope to acquire to some extent with some work, but it’d likely be a clumsy, broken form that would still miss the subtleties and nuances of the interview that only a native speaker can really distill out. By far my favorite part of the time I spent working in Mumbai in 2006 with children from various slums in the city was the relationships I formed with them—the conversations we had, the questions we asked of one another, the jokes we shared, the Bollywood songs we sang together. I can do that with neither the children nor their caregivers here, and it undeniably takes away from the clinical experience for me. My favorite part of being a pediatrician, after all, is talking to kids.

Balancing that, however, is the remarkably challenging, rewarding, and indeed humbling nature of practicing medicine in a setting like this. It reminds me of why I went into medicine in the first place, why I wanted to train in a combined program in Internal Medicine & Pediatrics, and what your limitations are as a physician. It’s an overwhelmingly clinical, conceptual, and collaborative undertaking. You rely on your physical exam, your knowledge of pathophysiology, and your colleagues for second opinions and input. There are protocols and guidelines for organizational purposes and structure, but these often have to be adjusted on the fly, reinterpreted based on your clinical judgment, or abandoned altogether given the circumstances. Problem solving and innovative adaptation is crucial. Not only are resources limited, they are often intermittent (like the internet). Last week the CD4 machine wasn’t working; the week before, the lab couldn’t run a Hepatitis B surface antigen test; for the past month, and until at least mid-November, the lone ultrasound technician in Maseru is away attending to a family emergency. So we managed HIV and antiretroviral therapy without CD4 counts; transaminitis and ascites without a Hepatitis B test; and hepatomegaly and abdominal pain without an ultrasound.

The pathology is also unique to the developing world. We see and treat countless cases of TB and Pneumocystis pneumonia, routinely deworm kids, ponder all kinds of diffuse, overwhelming rashes, which often seem like caricatures of zoster, scabies, and ringworm, and encounter in a normal day more moderate to severe malnutrition than I’ll see in my career as a physician in the U.S. We saw a bow-legged boy suffering from severe nutritional rickets just two days ago, something we only see in pictures in medical textbooks at home.

What’s even more difficult than seeing these conditions, though, is the realization that we often don’t have the resources to treat them. Malnutrition, often due to food insecurity, is perhaps the most sobering example. We have high calorie supplementation packets that we can offer to moderate to severely malnourished children, in hopes of avoiding hospitalization, but for most, we simply can’t provide food for them. The sight of an 8 year old girl who is at best the size of a 3 year old is virtually the norm here. And in another example of one of the many vicious cycles that pervade the lives of the underprivileged, malnutrition of course leads to a much greater vulnerability to disease. When your immune system is already weakened by HIV, it doesn’t take much of an insult to start a downward spiral.

Having access to antiretroviral therapy (ART) for children in this setting is a paradigm shift, and even a few years ago was unthinkable, so does represent a major advance. I initiate several children daily on ART, and the improvement in their health can often be dramatic over the course of mere weeks. But it’s a strange dynamic, since we don’t even have permetherin for scabies, let alone a CT scanner anywhere in the country. And I can’t help to wonder if this is a sustainable solution; I may be proven wrong, but I don’t think it is. How many years can you, as a government or NGO, afford to treat an HIV positive newborn with antiretrovirals when over thirty percent of the population is infected? HIV has become, for all intents and purposes, a chronic disease in the developed world. But chronic disease management, requiring lifelong medications, are almost without exception a prohibitively costly undertaking in the developing world. Can you realistically hope to procure antiretroviral medications for one third of your population for decades (if the program is successful at prolonging lives), even when they’re made by generic companies like Cipla for as little as $300 a year, when your per capita spending on health care is closer to $25 annually ($24.10 for Lesotho based on a 2001 WHO estimate, compared with $6,100 in the US)? And especially in this global economic climate, it’s not practical to rely too heavily on outside sources of funding to help.

This is of course why the most cost effective, lasting impact is in prevention, public health, and population based strategies. Prevention of mother to child transmission is a major area of work, and rightfully so, as with proper medication regimens starting at 28 weeks gestational age and lasting through between 1-4 weeks of life for the newborn, vertical transmission can be drastically reduced. An HIV vaccine remains for now the frustratingly elusive, holy grail of the international health world, largely because the HIV virus is so adept at evolving to evade efforts to contain it. In the immunological cat and mouse game, it exemplifies the power of natural selection, almost in real time, rapidly developing resistance to new strategies (pharmacologic, immunologic) designed to eradicate it. It’d be fascinating if it weren’t so devastating.

This weekend we’re headed to a town high in the mountains in Lesotho called Semonkong. It’s a treacherous drive up there, but it’s supposed to be a stunning place. There is an outreach HIV clinic there where we’ll spend two days working, but also will have some time for adventures like abseiling down a waterfall and trekking. I’ll keep you posted. Thanks for reading.

Much love from Lesotho,
Sachin

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More photos from Kruger & Lesotho:
http://sdshah.com/photos/southern%20africa_oct_2008/lesotho/

12 oct 2008 - kruger and back

This past weekend four of us went to Kruger National Park, in Northeastern South Africa, which was an ambitious road trip from Lesotho, especially given that we had only one full day to spend there. But it was undoubtedly worth it. Kruger is Africa’s most famous wildlife reserve, and it’s easy to see why. Roughly the size of Portugal, it’s filled with the big five of lions leopards, elephants, rhinoceri, and cape buffaloes, in addition to countless giraffes, hippopotami, warthogs, kudus, impalas, and a lot of other animals I couldn’t begin to name. We left early Friday morning for the 10 hour drive through South Africa, and aside from a 1.5 hour wait at the maddeningly inefficient border crossing from Lesotho, the trip was fairly uneventful. I expected it to be more difficult to get there given the convoluted route we had to take, but with a good South African road atlas and an attentive navigator, it was pretty easy.

We had booked a lodge just outside the park, and it turned out to be fantastic. Two stories, four bedrooms, wet bar upstairs, beautiful terrace, and a price that made you triple check the listing when you saw the place. We woke up early (4:15am) again Saturday and took an all day safari in a jeep through much of Southern Kruger with a fantastic guide named Heinrich, recommended to us by the guy who owned the lodge where we were staying. We spent the day in an open jeep, scouring the bush and open savannah for animals, and saw essentially everything but a leopard or cheetah. Though it was supposed to only go until 1 or 2pm, Heinrich went two hours over to take us to a spot where a group of lions often hang out, and the gamble paid off when we were able to see a pair of lionesses and two young males lounging in the shade. We were dropped off back at our lodge at 4:00pm just in time to get in our car and head back inside the park for a night safari, which was less personal and in a bigger jeep, but during which we saw a number of elephants, giraffes, rhinos, and buffalo right in our grills.

After scrutinizing the landscape all day for animals that have evolved to blend into their surroundings, I began to see creatures everywhere I looked. The view from the moving jeep was a motion picture: dry driftwood would morph into a giraffe with its head craned; from the tall grass would emerge a herd of zebras; a mound of dirt in the distance would become a lumbering rhinoceros. Heinrich, with eyes like a hawk, saw virtually everything, and was masterful at picking out for us the subtlest movements in the peripheries.

The park was unusually dry, and so normally rushing rivers were left only as parched beds of sand; and barren, leafless branches replaced the usually lush, green foliage. It did make spotting animals easier, especially since they all had to go at some point to one of the few remaining, well stocked watering holes. For the same reason, it made hunting easier for the predators, as was evident by the halting, cautious way the impalas, especially, would gingerly approach the exposed watering holes for a drink. For their sake, I hope it rains soon.

So after 14 hours of safari on Saturday, we went to bed early and slept in Sunday morning, then left after a big breakfast for the drive back. We went back through Swaziland, earning the added passport stamp by traversing this beautiful, mountainous, and greener (though still afflicted by the drought) land filled with acres of pine trees, rolling hills, and hairpin turns. We made good time back to Lesotho, and the border crossing back was painless.

Back in Maseru, we dropped off Dan, a medical student from Virginia who’s also been working here, and headed down the mountain on the road back towards our cottage. Here we were forced to stop by a pair of cars that were at a standstill in front of us, and were summarily greeted by a pair of men with guns in their hand who gesticulated for us to pull over to the side of the road. Convinced we were about to get mugged and perhaps carjacked, we did as we were told. A third man, who spoke English, came up to us at that point and began explaining that he was a policeman (a dubious claim, as he was not wearing a uniform, and there was no police car in sight), a man had just had his car hijacked there moments ago, and they were stopping people to check them. Then, somewhat inexplicably, after exchanging a few more words, he waved us through and let us go. I’m still not convinced they were really cops, but I am also at a loss to explain why he let us go without mugging us if he wasn’t. I suppose it’ll remain a mystery, but in any case we were pleased with the outcome, and it capped a weekend of adventure.

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5 oct 2008 - into africa

I've come for the first time to Africa this week, to spend a month working with a group called the pediatric AIDS corps (PAC) in Lesotho (le-soo-too), a small nation contained completely within South Africa's borders. One of my fellow Med-Peds residents from Rochester, Nina, has also come, and we made the trip over together. After a quick flight from Rochester to DC, it consisted of a 16 hour flight from Dulles to Johannesburg, a 22 hour layover, and finally a short, 75 minute flight to Maseru, the capital of Lesotho, on a 20-seat South African Air propeller plane. Our bags even made it on the first try.

Lesotho is a small, poor country, nestled in the mountains, and called southern Africa's 'kingdom in the sky.' It's a beautiful, mountainous nation inhabited by the Basotho people, who are historically farmers, cattle herders, and traders.

The PAC is a project run out of Baylor University in Houston, and has a number of locations throughout Africa. The clinic here in Lesotho is impressive. It's a new, glassy, spacious building with the first floor devoted mainly to a waiting room, a pharmacy, offices for social workers, a treatment room for higher acuity care, and patient care rooms. The second floor has administrative offices, a computer lab, and a lecture room. It's certainly the nicest clinic I've seen in a developing country, and in fact compares favorably to most of the clinics I've worked in at home in the US. Each patient care room has a computer, and the clinic runs an electronic medical record. In theory, there is supposed to be wireless internet throughout the building, but so far since I've been here it hasn't been working (one of the inevitable reminders that I am still in a developing country). There's a small pharmacy that stocks most of the medications we prescribe, and technicians there that assess adherence to anti-retroviral therapy (ART) each visit by counting how many pills remain in the bottles the patient and their caregiver bring back each time from the quantity dispensed at the previous visit. Anything less than 95% adherence, which has been shown to markedly increase the development of resistance to ART, is unacceptable, and aggressively addressed with a full assessment and further adherence counseling, as there are very few options for these patients once the virus develops resistance to the therapy. The first line regimens have to last years; there are limited second line regimens, and little to offer in this type of resource poor setting after that.

The disease burden here is intimidating, and produces some astonishing figures. A full thirty percent of the nation's population is HIV positive, and as a consequence maternal to child (vertical) transmission impacts an extraordinary number of newborns. Fifty percent of infants here infected with HIV die within their first year of life. Infant mortality rates in Lesotho exceed 130 per 1000 births, and HIV accounts for roughly 45% of those infant deaths. Also found here is the fourth highest incidence of tuberculosis (over 600 cases per 100,000 people) in the world, which is no coincidence given the burden of HIV in the population.

There are a large number of adult clinics for HIV/AIDS care in Lesotho, but hardly any other options for Pediatric HIV care. Through funding from the Ministry of Health and the Clinton Foundation, primarily, the clinic offers antiretroviral therapy (ART) to children with HIV, which is a medically complex and organizationally daunting endeavor given the unique challenges (e.g., minimal scientific data specific to HIV positive children, the necessity of weight based dosing, complicated regimens reliant on surrogate caregivers in the face of countless parents dying from the very disease they have passed on to their children) present in pediatric populations. Bristol Myers Squibb, the pharmaceutical company, also contributed a significant amount of money for the clinic building (which bears its name), and apparently contributes to the salaries of the Pediatric AIDS Corps (PAC) physicians who are here full time, but seems to have no involvement (based on my initial, cursory inquiries) in the funding or selection of the ART medications. Further investigations on my part are pending, stay tuned.

The clinic will offer HIV testing to anyone, child or adult, and though they see primarily pediatric patients, for those caregivers with multiple children enrolled in the clinic, pregnant mothers, and select other adults, care is often offered here when the time and transportation requirements of going to multiple sites for medical care is prohibitive. Prenatal care is also a part of the repertoire of care often offered at the clinic, care that centers around the administration of drug regimen designed for the prevention of mother-to-child transmission (PMTCT) of HIV, which ideally starts at 28 weeks gestation and continues up to several weeks postpartum for both the newborn and the mother.

The children we see are often extraordinarily sick. They are severely malnourished, immunocompromised, and afflicted, as a consequence, with a host of opportunistic infections like TB, Pneumocystis carinii (or jiroveci) or bacterial pneumonia, diarrheal diseases, candidiasis, dermatological diseases, meningitis, and severe sepsis. We seem to average at least 1 or 2 lumbar punctures (spinal taps) daily in clinic for lethargic infants that almost certainly have bacterial meningitis. We coded a little girl last week (twice), before stabilizing her and transferring her to the hospital. Maseru's government hospital, called Queen Elizabeth II, is not a place we like to send our children unless it's absolutely essential. It's a third world hospital – understaffed, overburdened, and crawling with cockroaches – and the outcomes of the patients sent there do not inspire confidence. That said, there are undeniable limitations of even the most aggressive outpatient management of serious medical problems (and the envelope is certainly pushed here) which quite simply require inpatient management.

Maseru has thus far lived up to most of my expectations from previous times I've spent with NGOs in developing countries. Rural and urban sites in India have to date served as my frame of reference and, in reality, there has been a lot about what I've seen here that is familiar from the places I've worked in India before. The poverty is pervasive, visible everywhere, and inescapable. Ubiquitous are the sheds with plastic bags or blue tarps for walls tied between crooked wooden beams supporting corrugated tin roofs; or else the short, squat, one room houses of brick situated haphazardly along the roadside. The overwhelming majority of Maseru's population lives in structures like these; they peddle vegetables and collect scrap metal; with a once thriving textile industry essentially destroyed by competition from China and a national unemployment rate hovering around 50%, they are migrant workers without jobs. The air is smoky from the cooking fires; hazy from the heat and pollution of the daytime; dusty from the wind blown roads.

There are many residential enclaves, however, tucked away in corners of the city that represent the pockets of wealth, and stand in stark contrast to the other Maseru. As in all developing countries, the dichotomy between the few 'haves' and the many 'have nots' is perhaps most evident in how the former group lives. These residences are often situated on one of the several mountainsides checkering and surrounding Maseru and offering spectacular views of the city and, most strikingly, the daily sunsets. I've already seen many of these areas as well, as most of the fairly cohesive, interconnected expatriate population resides within them. The small number of wealthy Lesotho families and expats (most of whom are working with various NGOs in the area) live quite comfortably, and if I were to come work here for an extended period of time, this is how I would live, too.

Aside from the other PAC doctors, I've met a Fulbright scholar from St. Louis studying the nation's history, a number of Brits working for a sports outreach NGO, a Welsh woman volunteering at the city hospital, another American working here with Partners in Health setting up solar power and satellite based internet access for remote villages in the mountains, and quite a few other expatriates doing (mostly) interesting work. They speak varying degrees of Sesotho (se-soo-too), the main dialect spoken here, know the city and country remarkably well, and have made comfortable homes for themselves.

There's also a fellow Princeton graduate, fresh from the class of 2008, and all around good guy, named Stuart, who's doing a yearlong post undergraduate public service fellowship program called Princeton in Africa. He's working with the clinic organizing various outreach activities and, as he has a car here (practically speaking, essential for anyone here long term), serving kindly and without complaint as our informal driver. It's not unsafe to drive here, most drivers are well behaved and things proceed relatively orderly, though it is advisable to avoid driving at night. But it's remarkably better than driving in India, for instance, where sheer chaos reigns amidst the congestion, two features that are happily absent here. I think there simply aren't enough cars on the roads to wreak that kind of havoc, perhaps speaking to the absence of a middle class. Urban traffic volume in a developing country probably does represent a surrogate marker for the emergence of that nation's middle class. Maybe. We're staying in a cottage next to the clinic, which while convenient for getting to work, is otherwise very isolated from where everyone else stays, and leaves us dependent on (mostly) Stuart's kindness to come pick us up and drop us off, which, fortunately for us, he does so willingly.

The PAC doctors, who are a tight knit group, have welcomed us warmly and wholeheartedly into their fray, a social network that includes most of the city's expatriate population. There has already been a birthday dinner party (enchiladas), guys only poker night (at which I won 750 Rands, which is the equivalent just under $100), Friday happy hour (at the swank Lesotho Sun hotel), trip to a local music and arts festival (in a town called Morija), and a Sunday brunch (banana pancakes) followed by a lazy movie afternoon (Kung Fu Hustle).

Despite rumors to the contrary, I'm doing just fine without internet, and passing my free time with downright equanimity. Between the busy social calendar and the frequent cooking, there is not an excess of free time. When I do have it, though, I'm reading, apart from all I can get my hands on about HIV care in resource limited settings, 'Don Quixote' at present, and taking breaks by playing hearts on my internet-less laptop (I shot the moon three times in one game last night en route to victory).

Four of us are trying to get a trip together to Kruger (huge, famous national park in South Africa, and the best place to see wildlife) this weekend, which would be at least an 8-10 hour drive, so we'll let you know how we do. More later.

Much love from Lesotho,
Sachin