Preliminary Results

After a long time gathering data in the basement of Mbabane Government Hospital, a Baylor doctor named Fiona and I ran the statistics on a total of 205 patients admitted to Pedatric Ward 8 from March-May of this year. Because of the political sensitivity of our results, I have been advised not to release our specific mortality rates over the internet. Much of this is caused by the fact that hospitals are being decried as deathtraps around Africa, and there have been articles in the Swazi Times lately stating that there is no real confidentiality of peoples' HIV results. Additionally, our clinic is partnered with the government, and so a great deal of discression is called for until the hospital staff has formulated their own stance on our findings.

Without being too specific, I can give a few of the broader details of our work. Let me start with the fact that our most well represented primary diagnosis for the Swazi children was severe acute malnutrition (over 1/3 of all admits) followed next by Gastroenteritis with dehydration and then pneumonia. Since HIV destroys the immune system, those infected are even more likely to be admitted with the aforementioned conditions, and that is exactly what we found. While we were surprised to find that roughly 3/4 of the patients knew their HIV status when they came in to the hospital, those numbers improved little if at all by the time a child was discharged, and the most common test for HIV had been given only about half of the time that it was indicated.

Because HIV is the most common cause of malnutrition here, we found the majority of the children we admitted to the hospital from our clinic were severely malnourished, and they comprised over 1/3 of all of the admitted malnutrition cases on the entire hospital ward at any given time. Since our patients accounted for such a large number of all of the kids at the hospital, we have a legitimate stake in what is going on there. While undoubtedly we see some of the sickest kids in the country, the typical mortality rate for a malnourished child with HIV in a developing country is right around 30%, but ours was significantly higher, with more than half of these dying within the first three days.

While the numbers we generated are clearly disturbing, they serve as a powerful tool to facilitate change and partnership from outside organizations. Among those currently collaborating with us are Action Against Hunger, the national Nutrition Council, and UNICEF. Our main goals to pursue in order to make a difference are twfold: to improve HIV testing on the ward and to improve the quality of care for malnourished children. The next question becomes, "How?" For one, we can promote accountability and leadership among the current staff by delegating tasks more efficiently and bringing in more trained HIV counselors and testers. Secondly, we can try to write our own malnutrition protocol and provide training for those who work at the hospital. Thirdly, we could try to mirror our sister program in Lesotho which staffs its own group of malnutrition experts and funds them through an outside non-profit organization, but this brings issues of sustainability into question.

One of the most difficult lessons for me here has been the eagerness to DO when I must learn to have faith that things will happen according to a greater design. There is a formidably fine line to tread when it comes to intervention in government health policy from an outside source, and any change we seek to implement will have to occur first with the Ministry of Health which translates into a long time after I leave this country. I suppose this is rightly so when the delicate balance of so many vulnerable lives is in question, but it's hard to tolerate when the faces of the little ones we follow on a regular basis disappear before they are made whole again. In the meantime, I will start searching for models and budgets that can give our ideas the feasbility to at least initiate the discussions that must take place among the various players involved. Always in the background are the children, and I ask you please keep them in your thoughts and prayers.

Lion King

I found this lion and these rhinos in Hlane, a park about an hour and a half drive from our clinic.

The Project

MGH. For most medical personnel who read those letters, they are inclined to think of Harvard's residency programs at Massachusetts General Hospital in Boston, but allow me to introduce the polar opposite acronym for medical training: Mbabane Government Hospital. After the guard removes the old stool blocking the entrance, one can walk inside the gate to find the initial view pictured at the top. Old and rusted, this Parkland of Swaziland's capital city is in far worse need of refurbishment than the county hospital in Dallas, TX.

Upon entering the entirely open air complex, I typically make my way up to Pediatric Ward 8 where I am greeted with the multicolored hallway in the middle photo, a sight much more welcoming than any of the other wards even if it betrays what lies within. Rounds begin with one of the two doctors assigned to the seventy or so admitted children, and while I try my best to listen and learn from them as we move from bed to bed, it is incredible how the anxious mothers look at me as if I possessed the great authority of a knowledgeable and practiced physician. Dr. Fiona Henderson from our Baylor Clinic joins us, and I try not to become too disconcerted as she tends to frequently disagree with the local physicians as to whether the underlying pathologies of many of the patients is related to Tuberculosis. She seems to think it is much more common here than it is usually diagnosed.... How bizarre it is to think this disease kills more people than any other worldwide even though it is nearly absent from the United States. Although it is transmitted through the air, there are no isolation rooms here, and every cough feels like a personal threat.

On my first day at MGH, I noticed that nearly every patient we encountered had moderate to severe malnutrition, much like the child in the final picture. When I asked her mother if I could take a picture of her apallingly small twelve year old daughter, who was now receiving her light-sensitive antibiotics through an IV crudely covered with construction paper to treat her cryptomeningitis, she accepted and simply replied, "Yes doctor, she will get better."

We continued on to finish our daily rounds, and I tried to ignore the bugs crawling on the walls of every "cubicle," which was just one of four rooms on the ward with around 15 beds in it. Eventually we halted on a child who had a feeding tube and had not been doing so well. Apparently, she had been gaining weight earlier in the week, but she had had some sort of crisis the night before which necessitated the IV in her head. Her stomach was very distended, and Fiona also told me that her heart was enlarged. We checked for signs of edema or swelling as one would for heart failure, and then Fiona repeatedly tried to put an IV in the miniscule veins of the toddler at multiple sites. She then asked me to get another doctor for help, but I knew the child had to be in bad sorts when she hardly changed her behavior in response to the needle sticks. When I finally found him, we brought the girl into the "treatment room" where Fiona put an IV directly into the bone of the patient's left lower leg. While the child was clearly not moving much, I was trying my best to stay out of the way until the gravity of the situation hit home when the nurse began doing chest compressions. I looked back and forth in angst from the kid to the gogo (grandmother in SiSwati) wondering all the while whether she had any clue of what was happening. Eventually, the little one's pulse returned, but she was not breathing which meant we had to move her to a place where she could get oxygen therapy. There were no ventilators here. After giving oxygen and more CPR, the doctors finally stopped knowing nothing more could be done. I looked at the gogo who just stared on silently and again questioned whether she had comprehended the chilling finality of what had just taken place.

When Fiona and I went back to the lounge afterwards, I immediately asked her, and she responded, "Oh yes. She knew exactly what was happening all along." Shocked by the answer, I promptly followed up, "Why was there no reaction? No tears or anything?" Fiona then explained that the Swazis were a very stoic people, and it was not in their nature to show grief in the way I had presumed.

Even though it had been hard for me to see a young teenager weep after receiving a diagnosis of HIV+, this was infinitely more terrible. The death of this young child was completely unremarkable. There was no flat line, no alarm from a sophisticated machine, no rush from a responding crash team, and worst of all no evidence of human pain or sorrow. Why? It was because death is an expectation here, especially when a child is admitted to the hospital. This was the Africa I had expected--ruthless and unforgiving.

The question becomes, what are we going to do about it in light of the fact that many of the patients who are severely sick when they come into our clinic are sent to this hospital for care? If we send them there, I believe they are still our responsibility even if they are not physically sitting inside of our building. To combat this discrepancy in care, Fiona and I have put together a database which contains all of the children admitted to MGH from March through May. Through various data points, we are analyzing first how many of the children that come in have a known HIV status and second how many of them are getting tested when they reach the ward. Because HIV, TB, and malnutrition are all profoundly interrelated (often tracking together), a child's treatment course will be profoundly changed depending on what the doctor knows about him when he first assesses and formulates his plan of care. Surprisingly, MGH actually has the resources to devote a nurse solely to the purpose of universal testing for all of the HIV kids that enter the ward but does not do it because the administration is so poor. Hopefully, our results will illustrate the common sense of this issue in a country throttled by HIV infection, and the hospital will implement this as a new policy. Additionally, we are compiling data on the indications and demographics of the children who are admitted for severe acute malnutrition and then comparing their mortality to the kids who are exposed to HIV versus those who contract new infections simply from staying in the hospital for an extended period of time. Tentatively, we have discussed creating a non-profit organization that would fund a much needed malnutrition expert to work full time at MGH, but there is a lot of work to do first before starting such a project. In the meantime, I will be rifling through charts and punching keys on a Baylor laptop in the medical records dungeon in the basement.

AIDS Bill In Trouble

PEPFAR, a bill that saves lives and represents America's commitment to fighting global AIDS, is being blocked in the U.S. Senate. I just sent a letter asking my senator push for immediate action on this critical legislation. This bill would provide resources for HIV/AIDS treatment and prevention for millions of people in the developing world.

Our leaders need to hear from us and understand how seriously we take America's moral leadership on helping the world's most vulnerable people beat deadly, but treatable diseases.

You can send a letter here: http://www.one.org/pepfarletter/

Thanks for taking action with me.

Environs

Here is the view from my front door and then the view from my back.

Where I Stay

Breakdown in the System

I wanted to include the picture of this patient and his mother to illustrate how widespread HIV is here. While diseases often track with socioeconomic status and level of education, AIDS has afflicted more than just the poor, and I think when one looks at this picture, it would be easy to assume that this photo was taken in the U.S. or anywhere for that matter. This woman is dressed in nice clothes and so is her child likely placing her in the Swazi middle class between the opulent monarchy and the destitute. (I should note here that the more educated Swazis are in fact worried that their king's promiscuous ways have him at a high risk of exposure which is likely true).
Like many, this woman has traveled some distance to refill ARV medications for her child, who is now doing quite well since starting the drug regimen. She first received counseling at a Salvation Army clinic, an unaffiliated outreach site, where they took a rapid test to prove she was HIV+ but then said she did not need a CD4 test. This is most certainly wrong since just testing positive for HIV gives no information on how far along in the disease process an infected person may be, thus providing a good example of a breakdown in the healthcare system and of what is perhaps the greatest challenge to the goals of lowering the number of infected people in a place like Swaziland. While the quality of care at the Baylor Clinic is excellent and exceeding World Health Organization standards, questions abound as to how best to deliver this care to people who are limited in their capacity to make return trips to the clinic on a minimally bimonthly basis to refill their meds or to be seen for follow-up.
Also, the mother is fortunate that she is the one who received the bad information and not her child. While most adults can live with HIV for about 10 years before it develops into full blown AIDS, young children who have not had the time to develop a mature immune system have a mortality rate right around 50% only two years post-infection. One other interesting point is that this mother claimed she could afford formula. This is incredibly rare in Swaziland since it costs about 300-400E per month, and it is critical that infants have it between months 6-12. Do the math in dollars, and that is a total of $300-400 which is an unimaginable amount of money for a population whose majority makes less than a dollar a day. There are also additional concerns as to whether or not the mothers can find/boil clean enough water to mix the formula so that the children do not contract additional disease, and even though breast milk can transmit HIV, it also confers protection against many of the pathogens that kill children in the developing world from lack of sanitary living conditions. With a low but still possible risk of HIV transmission in breast milk versus the risk of severe malnutrition in an improperly formula fed child, the recommendations of clinicians to their patients get much more complicated.