Sunday, August 31, 2008

Ghost Eyes

When I was eight years old, my life didn't depend on medication that I gave myself everyday. My caretakers hadn't left the country in search of work, and I wasn't left in the hands of a relatives who were illiterate and couldn't read the directions on my pill bottles. So how in the world can I pretend to understand what he's going through. He showed up at clinic at 9am this morning, probably waking up hours before dawn so that he can board a bus and travel down the mountain to make it to our clinic. We haven't seen him in over a year. We thought he was lost to follow up. We knew that he could refill his medication at a rural clinic in Roma, but had he? Has he skipped any doses? With HIV, resistance is most likely bred when pill adherence drops to the 70-90% range. In a medication taken once daily, that means that you can only miss 3 total doses. How many times have you walked out the door without taking a vitamin or a heart burn med? Let it drop lower than 70% and the virus cant be phased enough to be affected by "selection pressure." But make a half-assed attempt and you'll end up hurting yourself.

So there he is. He's been sitting in clinic now for over six hours. Its the end of the day and he's my last patient. His uncle is sitting in the corner. He must be younger than me. And his nephew looks up at me with ghost eyes. I see sadness. I see the loss of his parents. The tough choice his grandmother must have made when she left her mountain town to look for work in South Africa. I see a boy with entirely too much of his own care riding on his shoulders.

Has he been taking his medication? We ask for his Bukana - in Lesotho, patients possess a written summary of their medical record which is bound in a little notebook, carried along from birth to death. He hasn't brought it. We ask to take a look at his pill bottles. The best way to check and see if he's taking his meds. No dice. The uncle is all new to this.

It's surprising how there are some parallels to training in D.C., even out here. In the mid-eighties crack cocaine ripped though D.C., as in most other inner cities. With it came devastation, including HIV. And now, D.C. faces an infection rate as high as 6%, higher than many developing countries. That paired with economic woes have left many in the care of older relatives, and sometimes, during the transition, where new caretakers are presented with their new roles in life, care slips through the cracks. So I sit there with one of the other new PAC docs, and we struggle through a plan that will ensure this kid gets what he needs without risking him to drug resistance. Because when you're resistant to one line of drugs, here in Lesotho, you're only other hope is the second line. We don't have the testing abilities to tailor therapy like we would in the states. And by our estimates, 25% of our patients are already resistant to therapy. Second line drugs are more expensive, harder to keep in stock, harder to get our hands on. Some days, we run out of first line drugs; I don't spend a whole lot of time thinking about what happens after the second line.

I lift him onto the exam table. He's eight years old and 19 kilos. Forty pounds. He's eight years old and forty pounds. When I put my hand to his chest, the other holding my stethoscope to his back, his ribs lock onto my fingers, almost as if to shake hands. I can feel his heart thumping away at my palm.

What's it like to be so self reliant? To be able to count on no one else and have your life in your own hands. To be eight.

It's been a little more than two weeks, and I'm still struggling with the move. New country, new people, new language. I'm starting to know what it may have been like as an Indian immigrant coming to the States in the 60s. At times, it feels like a completely different world. But ghost eyes gives me purpose. Ghost eyes tells me that if I try really hard, I might make the smallest scratch in the giant ripping through the room. So we tell ghost eyes, after he points out the right pills on the picture card, that he's getting two weeks of meds. Bring back someone who can help, someone who can sit through the adherence sessions and learn what pills you need to take, so that if and when you get sick, you won't be alone. Come back to clinic in two weeks ghost eyes, and bring help if you can find it.

Monday, August 25, 2008

First Day Blues

I think the frustrating thing about this or any job is the feeling that no matter how hard you've worked up to this point, no matter how well you thought you trained, most all of it is for shit. Try drawing blood on the four year old who offers you his arm. Then f' it up and try three more times until he's kicking and screaming and you have a dirty needle flying through the air. Then repeat that a couple more times. Little things like that used to be a piece of cake, but today, on the first day, it's bound to be inches from impossible. After that, get reassigned to the "treatment room," where the really sick come to hang out because its better than the local hospital. There they spend hours bartering time, trying to get well enough so that they can prove to us that they'll make it through the night. Guess we'll find out tomorrow. And then there's the 4 month old girl with a rare skin condition called epidermolysis bullosa which you, oh yes lucky you, saw three years ago when you were living the first day to end all first days as an intern. Only then, your patient with said skin condition ended up on hospice because her fragile skin would peel away at the slightest trauma, the slightest touch. Her IVs would fall out, and within days, her skin had been stripped to nothing so that she was a gob of gelatinous, bleeding, pussy, pile of bandages and agony. And on the first day, you, yes lucky you, get to see her in the Treatment room. And you sir, are tasked with peeling away her old dressings, and inevitably a majority of the most supperficial layer of her skin, so that by the end of it, you really wonder if maybe she looked better when she first came in than she does now.

Oh first days. First weeks. First months. Nowhere to go but up.

But thankfully, first days offer redemption. Like when you pick up the four year old boy and his eight year old sister who you think might have tuberculosis. Go ahead, pull the trigger. Start the workup, order the films, start the meds which may finally end the year-long cough. It's a start. It's something to build on. And while there weren't any big wins today, I think I'll start with this little one. Because truth be told, I think that I'm in over my head. I worry that I'm in over my head. I know that I'm in over my head. So I'll start treading water, and if anything, use this as motivation to be more and do more than I had previously thought would be good enough.

Because truth be told, I am literally in another world. And I'm starting to remember that in this world it'll never be good enough.

Friday, August 22, 2008

Right-hand drive

Back in Houston, when we first met Kathy, we were asked what our
medical interests would be once we got to Maseru. Not having
specialists on staff, the new graduates were asked to pick a
particular role which they would like to fill in the clinic. There's
need across the board, but in the past, people have chosen to become
the resident expert on tuberculosis, outreach and suport staff
education, and epidemiology. I chose nutrition. I guess in my head,
I started romanticizing about what it would be like to "feed the
children"/tackle malnutrition in one the poorest parts of the world.
And of couse, I've started to realize that there's something
gratifying about feeding people.

So when we got our schedules a couple days ago, I guess I was kind of
expecting to have one loaded with time spent at QE2 (Queen Elizabeth
II Public Hospital). On the wards, PAC docs work hand in hand with a
local pediatrician, Dr. Pirri. Whereas hospitals in the states
are seen generally as the last stop when things get too bad to take
care of at home, it seems that QE2 has earned itself the opposite
reputation. Do everything you can to keep the kids out of there,
because if they end up on the wards, there's a decent chance that they
might not leave. Its also the last stop when malnourished kids are
unable to be treated at home or as an outpatient. After our intial
training is done, that's where I'll be headed next. Alone. It's got
me a little terrified, and as we sit here in the lecture room going
through current guidelines for everything from WHO Staging Criteria
for HIV infection to compliance training for the adolescent, I'm
scrambling to retain as much as I can. A lot of this material was
only mentioned peripherally in residency, if at all, and now as I
prepare to see it day in and day out, it makes me wonder how it'll
unfold. Time will tell I guess.

In the meantime we've been doing some shadowing with the vet PAC docs.
We follow them around as they pull patients into rooms and then try
to guess what we would do in that situation. I've been doing a lot of
guessing, and to be honest, I think I'm starting to get a handle on
some of it. Over the past couple weeks its been hard to keep things
in perspective, but I'm reassured by the fact that the fundamentals
for caring for a child in southern Africa are ultimately rooted in the
same foundation as caring for one back home.

Another surprise is how the days are filling themselves. Between
dinners and the weekly happy hour, most nights fly by. Last night
ended around 11:30 after 3 solid hours of South African Monopoly.
It's a little funny. All of the properties are listed in English and
Africans, and all of the currency has an extra pair of zeros to
accomodate for inflation. Tomorrow we head out to Bloemfontein where
we'll get a chance to pick up supplies in a South African chain
modeled after Target, and then we might get a chance to look for cars.
I myself had another big first today when Jeff, one of the vet docs,
tossed me the keys as we walked out of clinic. He's been trying to
sell his purple Volvo, and I guess I had coaxed him into a test drive.
Left hand drive on a manual transmission in the middle of rush hour
was entertaining to say the least, but we made it home safely, and
only after a handful of honks from other cars on the road. I kind of
felt like I was in driver's ed again. I was sitting straight up with
perfect posture and arms at 10 & 2, barely looking away from the road,
not even chancing a reach to turn off the heater which was getting
ready to lull me into submission.

In just a couple minutes we'll head out to Lesotho Sun for drinks,
then the chinese place Peace, (twice in less that two weeks!), and
then happy hour at a bar built into the big gym here. It's Jazz
poolside, or something like that.

Tuesday, August 19, 2008

Comfort food

We had a long day of training today.

A little bit of epidemiology, mixed in with a little bit of public
health, and topped off with a whole lot of clinical care guidelines.
All in all, I'd say we were a little wiped out by the time we got done
with work. On the ride home, Paul, Meena and I hopped out of the van with Smita and the four of us spent the evening at Smita's house unwinding. One of my new habits these days is imagining what I would be doing at that very moment if I were in the states. It usually starts of with me asking someone to turn on the tv, (which none of us own), and then asking where we're going for dinner (especially difficult as we are currently sans car). Tonight's craving was pizza
and beer, and so when I half jokingly asked if someone would call in an order, I was pleased to hear a chorus of voices clamoring for the same. 45 minutes we were enjoying Scooter Pizza, topped off with pineapple, and beer purchased at the local hotel. After dinner entertainment including South Park streamed on Smita's laptop, followed by part 82 of our ongoing debate on the merits of a nationwide public health approach to HIV vs patient centered care (the
Paul Farmer approach).

Monday, August 18, 2008

Welcomes

Today went generally pretty smoothly. After waking before dawn, (I
thought those days were over), I showered by candlelight - our
bathroom light only started working about an hour ago, and made my way
downstairs. Paul and I were picked up about half an hour later by
Dimpo. We made our way to clinic with stops to pick up John, and the
girls. Rolling into clinic before eight, we were greeted by awaiting
room was already full. Almost one hundred children and caretakers,
many elderly women who must have been grandmothers or distant
relatives, were huddled together, many wrapped in coarse colorful
blankets. We were greeted with a combination of curiosity, polite
smiles, and in some cases suspicion. I imagine we all looked a little
green, and I've come to realize that some patients get a little antsy
when they detect any hint of trepidation on the part of their
providers. And there was plenty of that to go around on our side.

8:30 sharp we reported to the waiting area and assembled for morning
prayers. Today was a little different in that the new staff, the six
of us, had to be introduced. And to herald our arrival, the entire
staff had assembled to sing a morning hymn. Usually a responsibility
relegated to patients, the fact that the staff wanted to sing this
morning had the veteran PAC docs buzzing. When they broke into a four
part harmony of literally the most beautiful song I've ever heard, I
was overcome with this incredible sense of well being. I think
there's something to be said about the power of song, especially when
applied to praise in a way that comes from a sense of knowing, and
longing, and joy. I envy other religions for that sometimes. Their
voices literally made the entire building resonate. I'm at a loss to
describe it other than to say it made me feel like I was stepping
inside from the icy rain, and being wrapped up in something heavy,
red, and incredibly warm.

Anyway, that was the highlight of my day, most of the rest of the day
was spent getting logistics out of the way and trying to salvage a
failed attempt at curried eggplant. Who knew you had to broil it in
the oven before you fry it up?

Sunday, August 17, 2008

Better and better

Lesotho has been growing on me in a big way. Yesterday Paul and I
walked down the road and caught a soccer/football game. Actually we
caught about two or three. All morning we had been hearing cheering
and the sound of a ref's whistle coming from over the hill. After
picking up supplies and getting back home, we realized that we didnt
have much to do. So we strapped on our shoes and made our way down
the hill. Instantly, all my concerns of being isolated were swept
away. As we walked through the fields and onto the hill that
separated two games in play, one a girls match, the other a men's
match that looked fiercely competitive, dozens of people looked our
way and said hello. A truck full of girls in the back of a pickup
even started shouting hello and singing a song for us. We got a lot
of attention. It's hard to say what was more entertaining: the
ongoing matches, or the subsequent celebration that followed every
goal, and ultimately, the end of the game. As soon as the whistle was
blown, a pickup would idle through the field making slow, tight
circles and onlookers would pile on and off the bed. Someone would be
blowing a whistle, another bellowing on a plastic trumpet, and another
would be waving a huge white flag. We couldn't figure out if this was
some kind of championship, or if every victory was herald with such
celebration, but it was fun to be an onlooker. With the setting sun
on our backs, I felt a little warmer, and much encouraged. It's hard
being in a new place. As I've mentioned before, the feeling of being
alone is especially pervasive.

With the night rapidly growing cooler we left the match and walked
about an hour through town and up a dirt trail that led to Friebel,
the main housing development where all of us will ultimately living.
We made our way to Meena and Lindy's, and then moved onto Smita's
house. By now it was dark and getting noticebly colder. As in any
desert climate, temperature changes happen pretty quickly and I've
been caught unprepared now a couple times. Walking through Smita's
doorway was literally like walking into a portal back home. Heaters
were on, the lights were up throughout her place, and music was
blasting. It didnt take long before we we're all giving in to Smita's
entreaties to stay for dinner - home cooked Chole. Over a candlelight
dinner we talked about the coming week and the transition we've been
making here. Just a couple of days ago Smita started tearing up at
happy hour. The rest of us had our own ups and downs and the impact
of the move started to really register. I think the hardest thing
that we've had to face is the feeling of total loss of independence.
Not having a car or means of regular transportation has been the
hardest. Actually I think my car lust is pretty much out of control.
Just twenty minutes out of town is Ladybrand, a South African border
town with a supposedly amazing vegetarian friendly restaurant that
everyone has been raving about. Smita went there with a couple
friends she used to work with here in Lesotho, and brought back the
most amazing chocolate mousse/cheesecake combo I've ever had. The
four of us at dinner polished it off as dessert.

Saying goodbye was tough, but we found ourselves right back over there
today as we met up for lunch. Yours truly made pasta sauce from
scratch. Afterwards there was dinner at a chinese restaurant at the
back of a chinese grocer. Our meal was punctuated by the sounds of
Chinese Karaoke. Apparently the textile industry is pretty big here,
with big manufacturers such as GAP buying garments from plants here.
In charge of those plants are the Chinese and they inturn manage low
paid Lesotho workers. Hence the Chinese are sometime viewed with a
wary eye. The restaurant itself was laced with iron bars and a
skeptical looking lady at the entrance. Just a few years ago, riots
has caused an even greater rift between the two communities.

I feel like eating, cooking, hiking, sleeping, and work will make up a
big part of living here. I can't wait for it to warm up though, the
views are spectacular and once things get setup, backyard parties are
apparently big. Barbecues are called "braai" here and much of the
social life here revolves around them. Thankfully I've stumbled upon
an abundance of fake meat/soy products here, including braai styled
links. Oh soy, I think I'm in love.

Tomorrow we head out to the clinic for our first day. My shirts are
pressed, I've got lunch in the fridge and I think I'm ready to go.
It's interesting hearing Kathy talk about the patient volume. Once we
pick up to full speed, each doc will see about 25 patients per day.
We work about four days a week, and have about 6 docs seeing patients at any time. So
thats about a five hundred patients a week. The compromise of course comes with standard of care. Kathy mentioned that its a fact that in order to see all those patients, you
have to get used to giving substandard care. Its hard enough to be
fresh out of residency without worrying about that, but this further
compounds that.

Over at a party we stopped by today, I picked up a book called 28
Stories of AIDS in Africa. Just a couple pages into it had me hooked
and got me really excited about the prospect of possibly, in some very
small way, being a part of the solution.

Saturday, August 16, 2008

Touchdown

After checking into the Jo'berg hotel, I ended up watching several hours of obscure Olympic
sports like hammer throw, badminton, greco roman wrestling, and some
new sport that was the combination of basketball and soccer.
Yesterday morning had me on a quick plane ride into Maseru, and I have
to say it was a little different than what I expected. From most of
the city there are foot hills which obscure any clear views across
town. That being the case, you feel like you're in a much smaller
environment...say a small mountain side village. We call them "hill
stations" in India, because they are usually only accessible by train.
There is dust in the air and the occasional smell of wood and
charcoal fires. The resulting smoke and dust kicked up the wind has
led to a subsequent haze but by this morning, it cleared to blue
skies.

I had a nice little surprise at the airport meeting the COE driver,
Dimpo, (pronounced Dee' - po). Not knowing who was picking me up, I
walked out of customs and saw a man dressed in jeans and a baseball
cap holding a cardboard sign saying "Bailor." Granted it was
misspelled, but not seeing anyone else and assuming that this was a
common mistake or perhaps a local spelling, I walked up to the man and
said "Baylor?" He said, "Bay-lah" with a big grin. Satisfied I
started walking behind him. He offered to take my bag, but I thought,
no its ok. As we walked towards the exit, it dawned on me that maybe
he was here to pick up someone with the last name Bailor. I tried to
engage him in conversation, asking about the rest of the group and
their arrival and he just kept on walking. Just then two men, one
large with dreads, reaching several feet back, and a distinct American
accent, the other, I later realized, was Paul. John started yelling
at me "Are you Raj? Raj? Hey stop!" I turned and as John explained
to me what was going on, the guy with the cardboard sign ran off.

John explained to me that someone had been paying off the central
government and getting inside information as to when the Baylor docs
were arriving. He would then race ahead of their drivers and pick up
the unsuspecting staff. After loading them and their bags into the
car, he would drive off into the hills into some remote area and
demand a large ransom or threaten to abandon them up in the hills.
The police were helpless and no one had taken the threat seriously,
and in the past months several visiting residents and one doctor had
been kidnapped in such manner.

John is explaining all of this to Paul and I as we walked towards the
PAC vehicle. As I drop my bags in the trunk the man starts
approaching us pretty rapidly. I murmur to John, "Hey man, I thinks
that's the guy." John whips around, his dreads flying. Suddenly the
other man starts running towards the car screaming "Dats my car! Dats
my car!" He rips open the passenger door and starts pilfering the
glove box. John races around and starts talking in Basotho. A yelling
match ensues and the other man pushes John to the ground. I look at
Paul and he's standing there with a confused look. I figure I'm the
closest, so I start running to John's aid, not really knowing what's
going to happen next. Fists clenched am standing in front of the
assailant. There's a pause, I wonder, "what next?" Just then John pops
up and explains "No, no man its alright." The other guys breaks out
into a smile, gives me a hug and welcomes me to Lesotho. And that was
Dimpo. Apparently that's a scheme that's been long in the works and
John only now found the right victim. Apparently I was the one least
likely to freak out, and on the plus side, I got free drinks for the
rest of the night.

Most of the rest of the day was spent touring the office, meeting the
other docs, all of whom are really fantastic, and running errands such
as buying a cell phone and getting settled in. Last night we ate at
this really great Italian place with surprisingly good pizza. I went
to bed last night under flannel sheets, with a full belly, and a
little bit of optimism.