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
