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.

Inferno e Paradiso

Inferno. Pagamile (Pax for short) is a nurse here who works in screening and self-admittedly is forced to cope with the burdens of diagnosis. I went to see my first case with him which was an 11-year old boy who had tested HIV+ even though neither his mother nor his five siblings had the virus. Confused and figuring the child to be too young for sexual or IV drug transmission, I asked Pax how this could be possible, and he replied that it was most certainly a case of abuse. I asked next if he had disclosed this explanation to the family to which he responded, "No. What he needs now more than anything is support and understanding." What evil could be more repulsive than the abuse of a young child save one that bears a death sentence to add to his suffering? Enraged, horrified, and filled with grief for this young one's plight, I did not quite know what to do as he walked away.
Pax then asked if I would like to see how the testing is done since I only saw him counsel the last child, and I obliged him. Three mothers and their children walked into the room, and for each we prepared a set of two "rapid tests," so called because they test only for the presence of the immune system's antibody to HIV and not for the virus itself. Because mothers' antibodies can be passed through breast milk, these tests are not accurate until after a child has quit nursing, but assuming this is no longer occurring, they do provide a method of definitively diagnosing a person as HIV +/-. Pax explained the clinic's services so the women would understand who would and would not be eligible for treatment based upon the results. As the few drops of blood were inked from each patient onto their respective testing strips, I could not resist the temptation to furtively (or so I thought) glance at each result. No number of times of hearing the Swazi's HIV statistics had prepared me for the reality that next confronted me. As the women politely sat there listening to Pagamile's counseling, I knew already that 3/6 were presently ignorant of the fact that at any moment, they or the person beloved most by them in the world would be told that a malady which had confounded the greatest of all mankind's science and brilliance more than any other in history currently inhabited the outwardly very normal and perfectly ordinary human figure that had strolled so plainly into the clinic that day. The suspense was stifling, and yet I dare not interrupt the talented, compassionate, and experienced Pagamile from his duty.
When it came time to counsel each pair of relatives separately about the results, I had thought I might scuttle off to shadow a doctor, but Pax asked me to wait. I obeyed, and when he came back, he asked me to see a pair of patients with him. Right behind me, a mother and her 15 year old daughter entered the room. Pax began to chatter away in SiSwati, and I could only hope I had not given anything away to the young girl by studying her every movement. When the news finally broke, no language barrier could mask the pain the girl suffered. Her countenance started with shame and avoidance. Next, she stared unblinkingly in seeming disbelief out of the window as if Pax's words fell on deaf ears. Finally, the tears started to come, and Pax passed a paper towel over the desk. The mother sobbed a little as well, and Pax extended her the same courtesy. Suddenly, there was a knock at the door, and Pax had to leave for a minute! I was terrified and felt wholly unprepared should I need to counsel the patients in some way with Pax not in the room. I sat there frozen in an eternity of waiting while the mother spoke softly to her child. Eventually, Pax returned and talked a little more before they started to leave the room. It was then that I realized how in this war on HIV, Pax was one of the marines, dueling on the front lines while the physicians were relegated to some other role. He commanded my greatest respect, but then I wondered, where were the heroes from my side of the team supposed to be? How could they not be involved with the very climax of what the medical profession refers to as the "therapeutic moment?"
I thanked Pax and told him how excellent his challenging work was, particularly having to fight not only the sorrows of positive diagnosis but also the frustrating refusal of those in denial. I moved on to see a doctor, and she asked how the morning was. How could I hold back from questions and emotions that I had not yet had the time to process? She began to explain how the level of cultural competency to deliver this kind of news and to reach out to the afflicted Swazis demanded someone of Pax's background and community ties. I did see the reasonableness of her point, and Joyce, our medical director, entered the room in the midst of our discussion. She began to define more fully the role of the physician as we started our next case.
The next patient we saw was a 27 month old boy who was HIV+. Three months ago, he could not even walk at his initial clinic visit, but he was started on ARV's. On this day, he toddled up to me with a big smile on his face and insisted that I share one of his peanuts with him! It brought me great joy to see the recovery of this type of developmental milestone in this child's life. After using this example, Joyce told me the awful state of the clinics before the arrival of ARV's in Africa in 2004. Even in the first month of the Baylor Clinic's opening in 2006, the trauma of AIDS had so devastated the people that the waiting room, always so regularly packed, was completely and utterly silent. Image the human condition so deprived of it's normality. And then ever so slowly, the children began to cry. A response. And as time went on, Joyce began to hear them run, play, and finally laugh. The sounds of children laughing: Paradiso.
Criticisms offered of my plans to go on this trip included the notion that those afflicted by HIV in a developing country were not curable and thus doomed to die. The hopelessness of the people was presented as an inescapable fact of life, one that would remain regardless of the greatest efforts of the educated and empowered. However, here I can see that this is simply untrue, and it causes me to ask if an individual with HIV who is on ARV medications is really so different in his personal struggle for a good life than any other who is chronically ill? Would a diabetic fare any better upon ceasing his insulin or a person with heart disease upon ceasing his statins? We human beings will all die eventually, but simply because our ailments burden us with sacrifice, they cannot prevent us from living in the meantime. It is here that I found the profundity in the role of the physician. Although we cannot evade the most formidable of blows that reality will inevitably throw against us, in the medical profession we stare irrefutable hardship in the face and ask, "Now where do we go from here?" We instill the virtue of hope, and our ability to nourish and embrace that belief is one of the most human characteristics of all. So let us go forth then to seek out the broken, to console the sorrowful, and to love as Christ once did.

A Bit More Detail

In the topmost picture, you will find a nurse checking a patient's adherence to the treatment regimen. Anti-Retroviral Drugs (ARV's) which are used to keep HIV from spreading in the body and commandeering a person's immune system require a fairly strict dosing schedule, and that is the reason we have such a rigorous means of checking patient compliance. If you can tell, the nurse is taking the patient's bottle and physically measuring out how many Milliliters of fluid is left in it and dividing it by the number of doses per day to see how well the patient (or more likely his caregiver) has been taking his medicines since the last time he has been in clinic. While this may seem a bit overzealous, I was shocked when I went through a number of medical records to find that the vast majority of patients averaged 95% adherence or more which I think is outstanding. Patients are sent to education and counseling again if they exceed a margin of 5% error in either direction of perfect compliance, and for various reasons (e.g. a homestead that requires a large amount of travel or a low level of caregiver education) I thought the clinic would struggle much more than it does in this area.

Another problem area in the delivery of good medical care in developing countries is the relatively small arsenal of tests that a physician who practices there has at his disposal. In the middle photograph, you can see the lab area which contains a centrifuge, a distilling machine, a device for measuring a Full Blood Count, and the CX4 in the picture which ascertains arterial blood gases and electrolyte levels from the patient samples. While these do give clinical clues, the chief values that a doctor would want when dealing with HIV are CD4 counts and a measure of the afflicted individual's viral load. For the last few years, those two tests were performed in the clinic but then sent to the Mbabane Government Hospital. The CD4 results could come back in a couple of weeks, but the hospital ran out of some of the reagents for the viral load, meaning it is not available. While these tests would be routinely performed in the US, the doctors here are forced to make clinical decisions regarding HIV solely by the CD4 counts which is sort of a poor man's test for viral load since other diseases like TB (which is common here and made more confusing since HIV patients are more susceptible to it) can also reduce the number of CD4 immune cells. However, the clinic is scheduled to receive it's own CD4 machine this week which should speed up the efficiency of care.

In the final frame is the clinic ER. For those acquainted with medical tehcnology, you will notice a bed, a machine for taking vitals, some oxygen cannisters, a couple of poles for hanging IV's, and even a crash cart were someone in an acute life-threatening situation could be treated. While this is at least something, it is still a pretty crude version of an ER, and I noticed that not only do they lack ventilators here, but also none are available at the government hospital either. The moral of this story is, if you need to go to the ICU, then get out of Swaziland because they simply do not have the resources here. Tomorrow, I will be visiting the government hospital in the morning, and I am sure I will be seeing a lot more of the limitations in the public sector.

The Clinic

Here is the story on the place where I am working. You can see the official title here on the welcome sign next to the front gate right off of Somholo Road. It is about a 20 minute walk up hill from the town center. The box on the top left of the sign is the Swazi flag indicating that this initiative is in partnership with the Swazi government. BIPAI on the bottom left is the organization that staffs this clinic along with 4 others in Africa and one each in Romania and Mexcio. Bristol-Meyers is the corporation that funds and makes this all possible, and hence you see this pristine looking building set in the middle of some random street oustide a little town in Swaziland (even if it is the capital). Most of the doctors on staff here are ex-patriots from the U.S. They actually get paid by a program called the Pediatric AIDS Core (PAC) which also pays off their education related loan debts in exchange for time spent both practicing and training health care providers in a foreign country. The PAC doctors are the ones with whom I see patients, and I typically rotate with a different one each day from about 7:30-4 Monday-Thursday and only until noon on Friday. I will give more updates on my specific projects soon.

What We Are Fighting

Much of this is taken from a recent article in the local paper Times of Swaziland:
"The seemingly out of control rise in HIV infection has been blamed variously on gender inequality that denies women, who are legal minors, a say in having children. Despite King Mswati III's declaration of AIDS as a "national crisis", little additional government funding has been allocated to combating the disease.
AIDS is a vicious cycle. The more we are in denial about AIDS, the more people who should be cautious are reckless, and the disease spreads. Because people refuse to believe how widespread AIDS really is, they shun known AIDS sufferers, and treat them as isolated, dangerous individuals.
A combination of famine and AIDS is threatening the backbone of Africa-the women who keep African societies going and whose work makes up the economic foundation of rural communities. More than 30 million people are now at risk of starvation in southern Africa, and all of these predominantly agricultural societies are also battling the serious AIDS epidemic. This is not coincidence: AIDS and famine are directly linked. Because of AIDS, farming skills are being lost, agricultural development efforts are declining, rural livelihoods are disintegrating, productive capacity to work the land is dropping and household earnings are shrinking- all while the cost of caring for the ill is rising exponentially.
In particular, as AIDS is eroding the health of Africa's women, it is eroding the skills, experience and networks that keep their families and communities going. Even before falling ill, a woman will often have to care for a sick husband, thereby reducing the time she can devote to planting, harvesting and marketing crops. When her husband dies, she is often deprived of credit, distribution networks or land rights. When she dies, the household will risk collapsing completely, leaving children to fend for themselves. The older ones, especially girls, will be taken out of school to work in the home or the farm. These girls, deprived of education and opportunities, will be even less able to protect themselves against AIDS.
Because this crisis is different from the past famines, we must look beyond relief measures of the past. Our effort will have to combine food assistance and new approaches to farming with treatment and prevention of HIV and AIDS. It will require creating early-warning and analysis systems that monitor both HIV infection rates and famine indicators. It will require new agricultural techniques, appropriate to a depleted work force. It will require a renewed effort to wipe out HIV- related stigma and silence. It will require innovative, large-scale ways to care for orphans, with specific measures that enable children in AIDS-affected communities to stay in school. Education and prevention are still the most powerful weapons against the spread of HIV."
In our clinic, maybe half of our patients are orphans due to the plague of HIV. Cursed from birth with a doom-spelling scourge, these children are the ultimate victims, born crippled into a world where survival of the fittest has never proved more relevant. Mt 25:40 "Whatever you have done for the least of my brothers, you have done for me. Whatever you have not done for the least of these, you also have not done for me." If the Christian gospel is to be taken seriously, we find that our mission is every bit as spiritual as it is scientific and economic.

Background

Swaziland. Where is it? Above is a map of Southern Africa, and you will find the tiny country of the Swazis (about the size of New Jersey) shaded in pink on the eastern border. To the left is a close up picture where you can see Manzini, the main business center of the nation pop. 80,000, and Mbabane, the official capitol pop. 60,000. I am currently based in the latter, and it is interesting to note that these are really the only two "big cities" in the country of approximately 900,000 people. This means that the vast majority of Swazis live in rural areas, and most of them strive to make a living as subsistence farmers.

Why did I come here? I'll give you the three 40's that stick out in my mind whenever people mention statistics. 1) An estimated 40% of the people here are infected with HIV. This is the absolute highest and worst rate of transmission in the entire world. AIDS is a humanitarian crisis here, and the thought of how this will impact future generations is sickening. 2) 40 years of age is the average current life expectancy, and if the current trends continue, that number has to be decreasing. 3) 40% of this country's GDP is made by the Coca Cola company which has a manufacturing plant here to take advantage of the essentially absence of corporate tax and the vast abundance of sugar in the region. That is not such a tremendous feat when you consider that 2/3 of the Swazis live on less than a dollar a day which by definition is extreme poverty. If anyone globally is in need of help, it is Swaziland, and what other place could better teach a person how to truly see their place in the world coming from the most powerful country in it?