An educational field trip

Friday, June 15

Yesterday, I had the opportunity to accompany two of the Baylor Pediatric AIDS Corps (PAC) doctors to an educational seminar that they were putting on in the beautiful village of Ntchisi (see picture below), about 80 km north of where I'm staying in Lilongwe. The doctors, Maria and Saeed, were basically there to teach 60 of the local clinical officers (a training distinction somewhere in between doctor and nurse), nurses, and other medical personell how to treat pediatric HIV. Ever since Baylor moved into Lilongwe, its doctors were in demand from hospitals around the country; so they established an outreach program in order to systematically bring pediatric HIV care up to standards even far outside of Lilongwe.

Ntchisi's one conference center where the day-long session was supposed to occur was double booked for the day, with the other party arriving first- so we had to jerry rig this old municipal office for our needs and shift the large audience up the road. We had in-depth HIV treatment booklets to hand out to all of the attendees, which made it easier for them to follow along what was supposed to be a PowerPoint presentation while the power was out. Despite the technical difficulties, we had a rapt audience the whole time.

From Saeed and Maria's presentations, I learned a ton about pediatric HIV management as did many of the attendees, evidenced by the range and depth of questions they asked. I also gained some insight into approaches to medical education at large. There was a "quiz" before the session to see where the largest knowledge gaps were; I also took and filled out a copy. Looking at our responses, it was revealing that the clinical officers/nurses and I each got about half the questions right, but our strong halves barely overlapped! I answered most questions regarding the theory of disease correctly (eg. the intrinsic difference between a PCR and ELISA/rapid HIV tests) but floundered with the clinical signs and procedures (eg. the tricky drug regimen invoked for a new patient with both TB and AIDS). They aced the clinical stuff and stumbled on theory.

Before coming here, I had the misconception that one needed a full-out theory backed education prior to implementing knowledge in a clinical setting. However, in a country like Malawi which has the resources for supporting just one medical school (zero as of a few years ago), produces only ~20 doctors per year, and all the while faces huge health crises, a theory based education is something of a luxury. Both theory and clinical knowledge are ultimately important to medicine, as knowing the science behind your diagnoses, procedures, and prescriptions is what ultimately allows you to adapt to unforseen situations and advance knowledge. But it is the clinical knowledge which is immediately applicable and absolutely necessary for their jobs; in other words, its the the questions that they got right which save lives, while the ones I got right pass exams. The clinical officers and nurses are for the most part autonomous in their own health clinics and small regional hospitals, and the onus is on them to learn pretty much everything they need by doing... I've gained tremendous respect for them!

Though I wanted to include "facts of the day" explaining both the theory and clinical knowledge examples posted above, I've run out of internet time. I'll tackle these next post :)

Social complexities surrounding HIV and treatment

Tuesday, June 12

As anyone reading probably already knows, the social circumstances surrounding the HIV epidemic can be equally as frightening and complex as the biological realities of the disease. Out of the fifteen or so HIV patients I've seen so far, one of today’s stands out as an illuminating example of these commingling factors.

The patient was an adorable baby girl, about 15 months old, who presented with clinical manifestations of advancing HIV infection and a new, low CD4 T-cell count, both of which were inconsistent with the fact that she’d been on antiretroviral drugs (ARVs) through the Baylor clinic for many months now. In reality, she should have been way better this appointment, months after starting her on drug therapy, than when we’d first seen her and diagnosed her disease status. Why weren’t the drugs working? Well upon taking the social history, we discovered that there was a time period of almost one month, occurring shortly after starting ARV therapy, in which the baby was not given her daily drugs. Why on earth would that happen? Rewinding some more, the mother revealed that she had tried to divorce the baby’s father after he took up another wife elsewhere (polygamy exists to a small but noticeable degree in Malawi), and he out of anger took away the kids for a month during which she was unable to trace him. Except, dad forgot to bring the baby’s ARV drugs on his retaliation-kidnapping spree. Hence, baby has gotten a lot sicker. But there’s more to this case than meets the eye…

Before continuing, let me insert some HIV info which is extremely relevant to this case: Everytime a virion enters and takes control of a human cell, it gains the ability to produce billions of new viruses, ready to infect new cells. Antiretroviral drugs, as the name suggests, act against the retrovirus (HIV in this case) by inhibiting its ability to replicate, with different classes of ARVs using different mechanisms to accomplish this goal. It was discovered years ago though that when a single ARV is used, HIV’s imperfect replication machinery (which has been slowed but not completely stopped by the ARV) will often create a few new viruses that are resistant to the effects of the drug. While the rest of the virus copies stagnate in response to the drug, these few resistant ones grow vast in number and you’re back at square one. This is why you always treat HIV with a combination of about three ARVs: you can more thoroughly halt replication in the first place, and out of the mutated strains which are created, even those that can beat one drug are stopped by the others. Unfortunately, when a person stops taking their ARV “cocktail” as this combo is sometimes called, it lets the virus out of dormancy and gives it plenty of chance to mutate so much that new copies of it can beat ALL THREE of the drugs, rendering the ARV coctail useless for that patient. When resistance occurs, CD4 cell counts are depleted (as they would in a patient not on any treatment) and opportunistic infections can easily gain headway, leading to chronic illness or death. The only option is to treat with an entirely new combination of ARVs. In the US, we have quite a few options to use. However, in poor countries like Malawi, there is often one “first line” and another far costlier “second line,” with no other options after those are exhausted.

Now, back to the baby girl in room 4. We call over the social worker and all together make sure that the father is as out of the picture as possible. Yes, the divorce seems to be finally going through; yes, thanks to the strong will of the mom, dad now understands that taking the baby away one more time will be essentially the same as killing her. OK, fine- we counsel the mother on the grave importance of sticking through on every dose of the second line drugs we’re about to prescribe, and makes sure she knows that any form of non-compliance to these will render the baby’s HIV untreatable. Finally, we teach her how to administer these separate drugs (far more complex than the convenient “three-in-one” pill first line) and send her home with them, in the back of our minds still worried that history might repeat itself, but this time offer no way out for the victim in the middle of it all.

First day at the clinic

Monday, June 11

My first day at the clinic has finally arrived. My housemate Nader (himself a doctor at the Baylor clinic) drove the two of us in by about 8 am to get started. The place is beautiful- brand new, well equipped, featuring a triage room, a procedures room, about seven examining rooms, X-ray, well stocked in-house pharmacy, staff kitchen, conference room, lecture hall, library, computer lab, offices, and I’m probably still leaving out a bunch. Every morning, there are about 50 or 60 patients and their parents – mainly moms – waiting in the waiting area. Some of them have literally walked about 10 km with kids in tow to get here while others have taken a 3 hour bus ride in the early morning; yet others came by some combination of those. And in line with BIPAI’s mission, all the patients are HIV+.

On any given day, some of the appointments at the Baylor clinic are prescheduled while many others are “sick visits” in response to any of the plethora of opportunistic infections that HIV+ kids are consistently plagued by. For life-threatening emergencies, we send the kids right next door to the pediatric ward at Kamuzu Central Hospital, where I will also get some chances to work starting next week. My role at the clinic, anyway, will be to shadow any of the clinic doctors during their days of office visits, eventually actually taking some histories and conducting physical exams on my own (with some supervision of course.)

Now for the HIV fact of the day:
I mentioned that all the kids we see are HIV+. In fact, in taking the social histories for any of the given cases, I realized that almost all of their mothers are as well. Here in Malawi (and probably in much of Africa) 90% of HIV+ kids under age 16 got the disease from their mothers, either during pregnancy when the virus crossing the placenta, during birth with their exposure to the mothers fluids, or during breastfeeding as the virus is present in high amounts in breast milk. This mode of getting the disease is referred to as “vertical transmission.” Without any kind of prophylaxis or precautions, an HIV+ mother will pass on the virus to a full third of her children. However, if she and the baby are given the antiretroviral drug nevirapine and the delivery mode is Caesarian section, the risk of vertical transmission drops to 2%. Considering that fact, vertical transmission is an all-too-frequent occurrence in the developing world often due to mothers not knowing their own HIV status or not having the resources to access this type of care.

Arrival in Malawi!

So… it was a long journey, but finally I’ve arrived- Lilongwe, Malawi!

This morning, my cousin Linda drove me back to the Jo-burg airport for my flight to Lilongwe. This time the plane was much smaller, there was no entertainment aside from the aggressive on-board duty-free peddling (their air stewards must be on commission), but the ride was smooth and short and there were lots of friendly people on board. Every Malawi resident I met seemed to know of the Baylor Clinic where I’ll be… certainly a good sign for how much headway the clinic has made in Malawi’s capital city during its short 8 months of existence.

I was picked up by one of BIPAI’s drivers, Francis, at the Lilongwe airport and driven to the Clinic itself, changing cash and picking up a cell phone SIM card on the way. I called home quickly and then went off to my new home (at least for the summer), a four bedroom place currently occupied by a doctor who will be getting in later tonight, and soon-to-be-occupied by more. The place is tidy, spacious, fitted with bednets, and generally perfect for my needs- I’m grateful to Baylor for providing it. What came as quite the surprise given the serene-looking surroundings of my house discovering that I have two night guards. Better yet, one of them goes simply by the name “Commander.” Sweet!

I spent the rest of the evening cooking some pasta for myself and the guards and reading the Baylor HIV/AIDS manual. From this point onwards, I think I’m going to include one random/interesting fact about HIV that I pick up from my work here with every post.

(Disclaimer: nothing in this blog should EVER be considered medical advice - I'm barely a quarter-way through med school!)

Todays fact: Post-exposure prophylaxis (PEP). If there’s a chance you’ve been exposed to HIV (eg. accidental needle stick, rape), you have a short window of opportunity to drastically decrease your chances of actually contracting the virus. It takes 24-48 hours for the dendritic cells in the mucous membranes and skin which initially receive HIV to migrate into the lymph nodes and on to the peripheral blood stream where they can spread it widely to CD4 T cells and others. Getting on antiretroviral drugs, particularly AZT, can actually stop transmission of HIV. (This is in contrast to drugs' roles in people who already have HIV, for whom they can only help contain the virus rather than eliminate it altogether.)

First stop: Jo-burg

June 7, 2007

My flight from JFK to Johannesburg, South Africa, a seventeen-hour ordeal, was made better by the facts that each seat had an entertainment system chock full of TV shows, videogames/chess, and movies and that the plane was only a third full. Most people on the plane, myself included, had a whole row to themselves to lie down and fall asleep.

I arrived pretty refreshed at Joburg around 5 pm on Thursday and was picked up by my second cousin Linda, of whose existence I had not been aware just 2 days earlier! The night before departure, my dad put together that I’d have an overnight stay in Joburg from looking over my tickets; when I’d mentioned the words “youth hostel near the airport” as a solution, the parental alarms went off and calls were made… lo and behold, my already gargantuan family now officially exists on six continents as opposed to the five I’d always assumed.

I am really grateful to Linda, her husband Sabu, and their three children for all the hospitality they showed me last night at their new house, including a night tour of the Joberg utilizing the little time I had there. Their house was palatial, fitted with all of the sweetest electronics, gardens galore, two three-car garages, and… actually located directly on a game reserve to boot! (Large fences protected their kids from the animals- but the views from their balconies were spectacular.) Their kids, Joann, Shawn, and Mikhail, all between 6 and 11, were a lot of fun and had great accents. Funny that two Indian parents decided on a Russian name; reminds me of my parents came up with an Irish one for me! I wish I’d taken a couple of pics with them and of the house during the daylight hours. Anyway, the overnight worked out much better than the original hostel booking. (To my fellow Eurotrip-05-ers reading this: remember Hostel Vesta “far from the best-a” in Prague, located directly in the main train station? Since then, I been wary about hostels affiliated with transit.) Unfortunately, I only have one night here...

Leaving tomorrow!

June 5, 2007

For people who don't know me, I'm Shanon Peter. I'm a 23-year-old medical student at Robert Wood Johnson Medical School in New Brunswick, NJ and a long-time resident of the Garden State (don't get me started on the irony). I'm a graduate of Morris Hills High School in Rockaway, NJ (2001) and of Harvard College (2005), as well as an "alum" of the Harvard Initiative for Global Health (Fellowship, 2005-06).

Aside from e-mail, school work, and some Facebook, I've never been a huge Internet user. Accordingly, this is my first blog post ever - but I am hoping it'll become a sustainable habit. Starting one of these is something I've been meaning to do for a while but never quite got around to. Finally, I have a solid reason for doing so, coupled with ample time to do it. That is, I'll be departing tomorrow for Lilongwe, Malawi in southeastern Africa, for what will be my longest foreign trip ever - close to two months. Actually, I was supposed to leave last Tuesday but bronchitis kept me at bay. (Mostly thanks to the assault on my body that was a memorial day weekend down the NJ shore with many of my old fraternity brothers... thanks guys. Nonetheless, the weekend was worth it, and this week after recovering gave me some much-needed time with my family.)

While in Malawi, I'll be working at the recently-opened Malawi Center of Excellence for pediatric HIV/AIDS, started and operated by the Baylor College of Medicine. During the weekdays, I'll be in the hospital from about 7-5; during the weekends, I might pursue a research project or go on excursions (I'm hoping to make it to Victoria Falls). I am forever interested in the intersection of social justice and medicine; and my late college and medical school coursework has piqued my interest in the field of emerging infectious and opportunistic diseases- many for which the HIV epidemic has opened the door. So upon considering my options for what those in the medical profession forebodingly call "the last summer of one's life" (the summer between the first and second years of med school), I thought that this would be the perfect fit. Let's hope I was right!