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/
