Monday July 2, 2007
I got back from an amazing four-day safari in South Luangwa National Park, Zambia. Its a busy day at clinic and I don't have much time to write now, so I'll let the photos do the talking this time :)
Thursday, July 19, 2007
Thursday, July 12, 2007
It takes a village...
June 27, 2005
One thing that has really struck me about Malawian culture is the strong and inclusive concept of family. This is especially evident in the Baylor clinic, where many of our patients have lost one or both parents to HIV. With so many orphans here, the cliché “it takes a village to raise a child” rings truer than you could ever imagine. Grandmothers, schoolteachers, mothers’ brothers’ wives’ friends, all play major roles in these childrens’ lives and from what I’ve seen, they are often happy to do so. I can still imagine the yelp for joy when I told a woman that her baby sister (who she acted as guardian for after both their parents had died of AIDS) had tested negative for HIV, and the tight hug of the baby girl which followed… though I’m sure she would have cared for the baby either way.
You hear all kinds of new descriptives for family positions here- for example, an eight year old patient was brought today by his “young father,” which meant his own father’s twenty-one year old brother, an affable and educated guy who has had full custody of the kid for the last three years since both parents passed away. While I myself can’t even imagine starting a family until at least my late twenties, here was somebody who stepped up and took responsibility for his HIV positive nephew at the dawn of his own adulthood. There was no agenda here- it was sheer family loyalty and duty that compelled him to give up many of the luxuries of being a carefree teen or twenty-something. And he seemed quite contented in his position to boot, taking pride in his nephew’s school achievements, helping the boy learn English at home, and showing deep concern for the boy’s well-being. We noted that the young father” had been so compliant in administering his nephew’s ARV regimen that we were able to lengthen the intervals between the child’s maintenance visits from two weeks to two months.
Though we see many positive stories of people like the “young father” or the many grandmothers, either taking on parenthood early or going through round two of it for the sake of their HIV+ kin, there are also too many kids that have nobody- or are not cared for by the few they have. At the hospital last week, I encountered an orphan male patient who was many hours from his home village undergoing what we thought to be Stevens-Johnson syndrome (SJS).
HIV fact of the day: Stevens-Johnson syndrome is an allergic reaction that starts with flu-like symptoms and progresses to circular lesions all over the skin and mucous membranes. When severe, it must be treated almost as a major burn- the fluids lost due to all of the damaged skin must be replaced intravenously, and particular lesion sites such as the eyes and throat must be monitored closely. Though SJS is rare overall (1 in 1 million incidence), HIV patients experience significantly more than that baseline rate especially because SJS can be provoked by the first-line ARV drug neviripine, as well as the sulfa drug antibiotics which all HIV+ children (ideally) take as prophylaxis. Mortality is about 40% for the untreated, as opposed to <5% for those given adequate hospital care.
To continue the story, as the boy was worsening, we heard from his uncle (and legal guardian) that they both needed to return to their home village or else the uncle would lose a lot of business at the grocery shop he runs. As much as the Baylor doctor-on-call Kebba tried to buy a few days for the boy in our hospital by explaining to his uncle that their local hospital would not have the ability to handle SJS complications and that transport there would be unsafe, he was not hearing it. Since the family had other relatives that live near to our city of Lilongwe, Kebba tried arguing that one of them should be called for and stay at the hospital with the boy so that the uncle could go back. That he still could not understand the logic of our argument baffled us. That’s when a nurse pulled us aside- she’d overheard the uncle speaking with a relative about what the REAL problem was: the uncle was afraid from the looks of the boy that he’d die here, and feared the cost of transporting the body back to their home village. This infuriated us, considering that the boy in question was STILL ALIVE and had a great chance of staying that way if cared for! However, Kebba was able to keep his cool and tactfully shame the uncle into letting the boy stay… after which he recovered and all was well. So I guess it took a village after all, with this one including a doctor that cares.
BTW- the picture is of me on a day trip into the actual village nearest Lilongwe… but I thought it’d be appropriate ;)
One thing that has really struck me about Malawian culture is the strong and inclusive concept of family. This is especially evident in the Baylor clinic, where many of our patients have lost one or both parents to HIV. With so many orphans here, the cliché “it takes a village to raise a child” rings truer than you could ever imagine. Grandmothers, schoolteachers, mothers’ brothers’ wives’ friends, all play major roles in these childrens’ lives and from what I’ve seen, they are often happy to do so. I can still imagine the yelp for joy when I told a woman that her baby sister (who she acted as guardian for after both their parents had died of AIDS) had tested negative for HIV, and the tight hug of the baby girl which followed… though I’m sure she would have cared for the baby either way.
You hear all kinds of new descriptives for family positions here- for example, an eight year old patient was brought today by his “young father,” which meant his own father’s twenty-one year old brother, an affable and educated guy who has had full custody of the kid for the last three years since both parents passed away. While I myself can’t even imagine starting a family until at least my late twenties, here was somebody who stepped up and took responsibility for his HIV positive nephew at the dawn of his own adulthood. There was no agenda here- it was sheer family loyalty and duty that compelled him to give up many of the luxuries of being a carefree teen or twenty-something. And he seemed quite contented in his position to boot, taking pride in his nephew’s school achievements, helping the boy learn English at home, and showing deep concern for the boy’s well-being. We noted that the young father” had been so compliant in administering his nephew’s ARV regimen that we were able to lengthen the intervals between the child’s maintenance visits from two weeks to two months.
Though we see many positive stories of people like the “young father” or the many grandmothers, either taking on parenthood early or going through round two of it for the sake of their HIV+ kin, there are also too many kids that have nobody- or are not cared for by the few they have. At the hospital last week, I encountered an orphan male patient who was many hours from his home village undergoing what we thought to be Stevens-Johnson syndrome (SJS).
HIV fact of the day: Stevens-Johnson syndrome is an allergic reaction that starts with flu-like symptoms and progresses to circular lesions all over the skin and mucous membranes. When severe, it must be treated almost as a major burn- the fluids lost due to all of the damaged skin must be replaced intravenously, and particular lesion sites such as the eyes and throat must be monitored closely. Though SJS is rare overall (1 in 1 million incidence), HIV patients experience significantly more than that baseline rate especially because SJS can be provoked by the first-line ARV drug neviripine, as well as the sulfa drug antibiotics which all HIV+ children (ideally) take as prophylaxis. Mortality is about 40% for the untreated, as opposed to <5% for those given adequate hospital care.
To continue the story, as the boy was worsening, we heard from his uncle (and legal guardian) that they both needed to return to their home village or else the uncle would lose a lot of business at the grocery shop he runs. As much as the Baylor doctor-on-call Kebba tried to buy a few days for the boy in our hospital by explaining to his uncle that their local hospital would not have the ability to handle SJS complications and that transport there would be unsafe, he was not hearing it. Since the family had other relatives that live near to our city of Lilongwe, Kebba tried arguing that one of them should be called for and stay at the hospital with the boy so that the uncle could go back. That he still could not understand the logic of our argument baffled us. That’s when a nurse pulled us aside- she’d overheard the uncle speaking with a relative about what the REAL problem was: the uncle was afraid from the looks of the boy that he’d die here, and feared the cost of transporting the body back to their home village. This infuriated us, considering that the boy in question was STILL ALIVE and had a great chance of staying that way if cared for! However, Kebba was able to keep his cool and tactfully shame the uncle into letting the boy stay… after which he recovered and all was well. So I guess it took a village after all, with this one including a doctor that cares.
BTW- the picture is of me on a day trip into the actual village nearest Lilongwe… but I thought it’d be appropriate ;)
Some thoughts on road safety
June 25, 2007
Today on my morning walk to the hospital and clinic area, I saw one of the most horrifying sights of my life. Two men who were riding in the back of a pickup truck, sitting on the ledge of its bed as is customary here, fell off of it after a big bump. The truck was probably going about 40 mph, so their tumbling and rolling on the ground after the fall was none too subtle. The two of them landed about 10 feet in front of me on the footpath I was walking. One of them looked seriously injured with possible broken bones but was conscious; the other started violently convulsing, his eyes rolled back and his arms and legs flapping a length of about one foot back and forth. A crowd quickly formed around them and then quite a few eyes drifted over to me- I looked down and realized that the stethoscope dangling around my neck probably made me look like a medical godsend for the whole situation. Little did any of the passers-by realize that I was but a rising second-year medical student with minimal clinical experience! So as I was approached to help, I had to take the particularly cold stance of waving my hands in refusal. Instead I called up the hospital on my cell phone to let them know what was about to walk in the doors, and then directed the driver of the now-backed-up pickup to the hospital’s emergency room, luckily less than a half mile away.
I didn’t get a chance to follow up and see what happened with the two men, both healthy-looking laborers in the primes of their lives, probably on their way to a morning worksite. Unfortunately, based on the serious accident victims I’d thus far seen in the pediatric ward, I fear the worst for the convulsing one. Head trauma is one thing Malawi does not have the capacity to adequately identify or treat, considering that the country has no MRIs and only one CT scanner (which is located in the other major city five hours away and has been broken for the past month to boot). I still hope and pray for his recovery, but as he was picked up and placed back in the truck for the ER visit, the realist in me accepted I probably just bore witness to the beginning of the end of a perfectly good human life.
As shocking as this incident was from up close, the overall trend that it fits into is even scarier. In Malawi and a good part of the developing world, road traffic accidents are fast becoming one of the leading causes of death and disability. An overly simplified version of a convincing explanation that I heard presented once at Harvard by the head of the World Bank’s Road Safety group (I believe Tony Bliss was his name), is that creation of roads has far outpaced the ability of developing nations to maintain them and adequately regulate their use. At the heart of the matter is that grants are most quickly given, debts are most expediently forgiven, and political will is most easily garnered in these countries in the name of expanding the road network. This action fulfills one of the classic, easily measurable benchmarks of “development,” while the well-being of people who will be using those roads is often overlooked from the funding standpoint. Anecdotal case-in-point: Malawian road traffic control (an oxymoron if I’ve ever seen one). Aside from the one police vehicle that I’ve ever noticed during my entire stay here, all of the police I’ve seen have been on foot and located at well-known checkpoints. In order to “pull you over” they have to (1) catch you doing something illegal within eyesight of their checkpoints; (2) literally flag you down, hoping that you will actually stop for them because they can’t do anything if you decide not to; (3) not be influenced by small bribes that the driving elite of Malawi can easily afford; and (4) hitch a ride in your car to the police station to issue you a ticket! One of my friends here was in the back of an overflowing, unregistered pickup which upon being flagged by the police just drove off-road into the bush for a few hours until he was relatively sure that no more cops would be looking for him anymore. As you can imagine, people drive whatever speed they wish here, pack unfathomable numbers in their small trucks (20 is not unusual), weave around the giant potholes left behind in last year’s development “project” of a road, pass each other even in the face of oncoming trucks, and have astonishingly little regard for the myriad bicycles, pedestrians, and animals that share the roads. And don’t for a second think that seatbelts or bike helmets factor into the whole picture. Something’s gotta give… and I got a little taste of what that something is this very morning.
Wednesday, July 4, 2007
A week in the wards
June 22, 2007
After spending last week at Baylor's pediatric AIDS clinic, I spent all of this one in the pediatric ward of neighboring Kamuzu Central Hospital. KCH is where any of Baylor's 1800+ patients go when they become acutely ill and require inpatient treatment- so at any given time, at least one or two of Baylor's doctors are assigned to work the wards rather than the clinic. This week, I shadowed Anjalee.
The first day in the KCH pediatric wards was pretty shocking. (The picture above is really not representative of the week as a whole, but rather is from of the happiest moments with an almost-recovered patient who wouldn't leave my side.) From the outdoor courtyards in which dozens of mothers were washing clothes and preparing meals, to the three huge rooms of about 40 crying pediatric patients each, the sheer crowdedness of the whole scene overwhelmed me. Add to it all of the various hospital smells that wafted in from room to room, and you'd wonder whether anyone could ever recover from anything there. To the contrary, the end of my first day marked my first direct encounter with a patient's death. We had a 13 year old patient, Calvin, in the "high depenency unit" (HDU) with an acute febrile illness which we were not able to figure out. After assisting with a lumbar puncture on what seemed to be a much more serious patient, I returned to the HDU to find that Calvin had convulsed about 10 minutes earlier and was now dead, probably of a brain bleed- it turned out that he was a known hemophiliac. Now, I understand that throughout my career, I'll need to be prepared to deal with death- but this one really caught me by surprise and hit pretty hard.
In the wards here was the first time that the phrase "resource poor," which is thrown around all the time in public health and development literature, really began to hit home for me. Its not just that they don't have money here (they don't), but some truly necessary medical equipment does not exist in the entire country of Malawi. Case in point: we had another girl in acute renal failure from glomerulonephritis (an attack of the kidney's filtering ability), who hadn't passed urine for days and was thereby retained all of her water, making her one of the puffiest children I'd ever seen. According to the doctors, she probably could have gotten over her acute renal failure with just a few rounds of dialysis, allowing us to treat the cause of her illness. However, unlike in the US where dialysis is readily available in every city and small town, we were not able to put the proper equipment together for her after calling in favors from across the country. We had a hemodialysis machine but lacked a pediatric catheter- necessary for the patients 6 year old arms- and we knew of a peritoneal dialysis machine but had no fluid to use in it. By Thursday things were getting desperate and I contacted my uncle - a South African nephrologist - to see if he might be able to find one or the other and express ship it to Malawi. By the next day, he'd drummed up 24L of PD fluid and we contacted Air Malawi to help with shipping it here. Unfortunately, this effort was futile: right before the fluid was to be shipped, the girl suddenly took a turn for the worse and died. It was in all regards a death that never should have occurred. All in all, this was definitely a tough week for me to take in- but far worse for a few of our patients.
As bad as some of those anecdotes seem, I have to say that among our hospital's limitations, there were some really positive things happening there. For example, Anjalee and one of the other Baylor doctors started a study documenting the progress of a switch to "Plumpynut" calorie-filled peanut butter as a staple food for all children in moderate malnutrition status or worse. By procuring large quantities of this food and allocating it based on medical criteria, they methodologically showed that malnutrition can be combatted in a big way even in as poor a place as Lilongwe. The Nutritional Resource Unit, currently the emptiest ward with less than half of its ~60 beds full at any given time, used to have up to 3 children per bed just about one year ago, with high mortality rates to boot. Though the people here probably haven't gotten that much wealthier in a year's time, science and dedication has made quite an improvement. I am optimistic that there will be more success stories in the coming years as knowledge of and funding for international health picks up.
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