Wednesday, July 30, 2008

The Return of Lorenz; AIDS

The Return of Lorenz; AIDS

As you can see, I’m feeling better. Several things helped. Wednedsay, I spoke with Dr Ester, an expatriot American doctor (the only MD within miles) who was the medical director for several years at the hospital before starting a local clinic of her own. She echoed my experience of Tanzanian medicine: treating for several things at once without a clear diagnosis, sending malnourished kids home (likely to die) after “health education” because the hospital didn’t have money for inpatient feeding, and frequent death you can do little about.

Shortly thereafter, Dr Kitono gave me a book I wish I had upon arrival:

Guidelines for the Management of Common Illnesses with Limited Resources.

A 378 page manual put together by the World Health Organization, it’s got everything I was dying to know. I had spent hours trying to download it over the slow dial up modem internet and finally gave up. With this book, I had a cookbook manual to help me with diagnoses and treatments of exactly what I was seeing. In short, turns out what I was doing wasn’t too far off from their recommendations. I wish I would have downloaded it at home and brought it (I think Nishant told me to do that, and I blew him off, figuring I could just learn from experience what I would need. Once again, brilliant, Lorenz, brilliant).

Thursday afternoon, I got back into the grove at the hospital with some procedures. A nice big lac repair—of a young farmer who was trying to get me to find him an American wife. (Ladies, any takers???). I told him I was having enough trouble finding myself a wife, but if there were any American women looking for a Tanzanian farmer, I’d be sure to send them his way.

There were 4 C-sections I missed when I was at the clinic. Initially, I was disappointed, especially because I was going to be the primary again, and I was ready for a second chance. But then I heard that on the first one, both the baby and the mother died—the mom had been kicked (domestic violence) and had uterine rupture with uncontrolled bleeding, DIC and death. Horrible--and the place of women in Tanzania, not good. Could blog on this topic for a while, too. Anyways, probably a good thing that my recent improvement from clinical depression wasn’t tested with the death of BOTH the mother and child. I might have packed my bags for home if I were the primary on that one. Whew. Very sad situation though. I'm not sure how they go about criminal proceedings here, or for that matter, if they will pursue anything or not (horrible, I know). My nervousness about the labor and delivery practices is not improved either (she had been in L&D for several hours with fetal heart monitoring only TWICE DAILY; I should discuss this more later.)

My last clinical day was Friday, and I got conned into rounding on the peds ward again alone. But I had my trusty WHO guide, which mitigated my frequent feelings of uncertainty. After that, I hung out in the outpatient HIV/AIDS treatment center. To my surprise, I didn’t see very much HIV/AIDS in the hospital. My expectation before coming was that AIDS was ravaging this continent and country, and was the leading cause of death. In my experience, most (80 %) hospital admissions were related to malaria. There were only a few cases of AIDS during my 2 weeks. Of course, those cases were bad news, with very poor prognoses--end stage.

Internationally, AIDS is a sexy disease. Very political. The hospital receives a substantial amount of US grant money (from Bushy, believe it or not) for AIDS drug therapy. The greater killer that I saw (malaria) doesn’t make those headlines or bring in such international gifts. It fooled me too—I’m going to the International AIDS Conference in Mexico City a day after returning from Tanzania. Two years ago in Toronto, there were 20-30,000 people interested in AIDS (not just doctors and medical professionals, but politicians, social workers, affected individuals) at the conference. It will be a great conference—I’ll be immersed in learning about the disease with the newest info, will make friends and meet inspirational people, in addition to making professional connections. And I’ll run around in Mexico City, the second largest city in the world. No doubt, it will be a great time.

But I’m not planning on going to the International Malaria Conference. Or the World Diarrhea Forum, if there are such things. I bet there’d be a bunch of nerds at the malaria one. Anyways, just pointing out I’m as guilty as the media about sensationalizing certain diseases over others that are arguably, just as worthy of attention. Tuberculosis too.

Back to the outpatient treatment of HIV, which is quite different from home. In the US, we rely on lab tests (CD4 counts and HIV viral loads) to determine when to start medications. When the T cells are low and the viral load is high, you start meds. Theoretically in Tanzania, they are supposed to follow patients with labs too. But in Shirati of course, they lacked the money and lab supplies to do so. So they follow clinically. Instead of having a nice quantitative number, you ask patients about their history and what diseases they’ve had related to HIV, and you stage them accordingly. AIDS wasting syndrome, characterized by >10% weight loss where somebody looks like a skeleton, would get drugs immediately (Stage IV). As would several months of diarrhea, or Kaposi’s sarcoma, or pneumocystis pneumonia—all so called AIDS defining illness. As opposed to generalized lymphadenopathy (stage II) or oral thrush. By themselves, they don’t warrant treatment yet, so you just follow the patient every couple months.

Different and interesting to treat clinically. More difficult to initially grasp, too. Treating based on 2 lab numbers versus being able to identify and diagnose 20 AIDS related diseases.

Also surprising, many of the same problems we encounter in the US related to HIV care—poor social situations, medication noncompliance, uneducated patients—are present here. There were miscommunications about meds—one patient stopped taking them for a month because he didn’t know he was supposed to keep on them. I’ve heard people say viral resistance to medication is less of a problem over here, but I suspect resistance will emerge all too soon.

There were patients of all ages—from 5 to 60. Many sadly, had survived their spouses and even their parents, who I suspect in many cases died of AIDS. Many of the pediatric cases were orphans. Sad. Kids and AIDS, there’s a subject I’m not in the mood to rant about. Talk about injustice. Largely treatable and preventable—if the mother is tested and known positive, she can be treated during pregnancy and surrounding birth, and the transmission rate to the kid can be as low as 2%. Not bad. Without it, people say anywhere from 15 to 40 % of babies born to HIV + mothers will become positive. Many children then are infected with an incurable often life taking diease, that could have been prevented 98% of the time.

That's about all I have to say about that. For the AIDS nerds in the house, they only have like 5 antiretrovirals (compared to the 40 we have)--including AZT, 3TC, efavirenz. They use a 3 drug combo for HAART, 2 NNRTI and a NRTI. No protease inhibitors. And the patients dont have to pay for them because of the international/Tanzanian government programs. That's a good thing.

1 comment:

Anonymous said...


Malaria may not be sexy, but the Gates foundation is doing some serious funding on eradicating this disease. Don't know how much progress they've made. Just that that's one of their goals.

Aunt Cath

P.S. Thanks for the shout out. Glad you're continuing the blog through the AIDS conference.

P.P.S. Gram gets her hardware off on Monday. She can't wait! I'm at 24 days and counting....