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.