Tuesday, February 14, 2006

Part One - Medicine

I've only had time to write my impressions of Swaziland up till this point because of my lack of internet access. So I guess I should write some more concrete entries right now.

Firstly: No-one uses the term "AIDS" anymore. What they used to call AIDS is now WHO Stage 4 HIV Infection. Interesting, huh? The WHO stages are a bit more detailed and useful than the whole HIV/AIDS distinction. In a way it's a good thing that they've let go of that. AIDS is a pretty stigmatised word, and HIV sort of conveys a bit more hope, I feel. AIDS is a terminal illness. HIV is a chronic treatable condition. That sort of thing.

Secondly: Swaziland is not a rich country, by any means, but it is also something like the 3rd richest country in sub-Saharan Africa in terms of GDP per capita. Starvation is not a problem there. Everyone is NOT living in huts. There is no civil war. One of the biggest problems with the healthcare system is the lack of primary care- GPs and community services like nursing and physiotherapy. There is a SEVERE doctor shortage, much much worse than anything that Australia can complain of. Its capital is Mbabane, where we were living. The main export is sugar. There are a reasonable amount of expats, especially Chinese, sub-continental and white, but it's not as cosmopolitan as South African by any means.

I spent my days either at the VCT (care and voluntary counselling and testing centre, or basically "HIV outpatients") or the wards. I would say that my first impression of Mbabane Government Hospital was simple: "I could work here". Despite the high workload, the doctors were friendly and cheerful, going through their business with smiles and jokes, relaxed. The medical hierarchy really wasn't evident at all. Everyone worked together roughly as equals and the patients too were treated as equals. Apparently this is due to the local culture- respect is very important. People refer to each other as "ba-be" or "ma-ge"- sir or madam. Your patients will greet you heartily in the street having seen you in the clinic. "Hi Doctor!" I heard almost every day, grateful patients greeting my cousin, Priyani, who was also the head of the Department of Medicine there.

VCT, in a new building funded by international sponsors, was always chock-full. Unsurprising, really, in a country where roughly 40% of the population is HIV positive, I guess! They offered pre- and post-test counselling, free testing and follow-up care. So, Mondays and Thursdays were their busiest days, because they were previously the 2 days that VCT was open. Tuesday was paediatrics.

There were 2 doctors there, Dr Takuva and Dr Mlawanda who were both from Zimbabwe. Dr Mlawanda, who was a short, heavy-set guy, with a loud voice. curiously, wanted to be an ENT surgeon once but sadly ran out of funds for postgrad study. Dr Takuva was tall, slim and unconventionally handsome and was studying for his UK physician part ones. In between discussions of hepatotoxicity with antiretrovirals (HIV drugs) and regimens of TB treatment, we'd often sit there discussing things as diverse as the war on Iraq, implicit racism, TV and hospital politics. The friendly banter about US foreign policy flying between between Dr Takuva, a conventionally liberal guy who was anti-war and Dr Mlawanda who was pro-war often made me laugh! Dr Mlawanda had a habit of running off early every now and then. Dr Takuva only really escaped once, apparently to meet a lady friend...

So, the doctors sat in a room with 2 desks, seeing one patient each. As you can imagine, the privacy was not great. In terms of confidentiality, it is of course kept, and it's illegal to divulge someone's HIV status. However, I guess, they are actively encouraging people to admit their status and be open about it- for good reason. In a country with a high rate like this one, and also a lot of unprotected sex, that is important.

There was also usually a couple of Swazi girls there interpreting and helping out. However they had a habit of absconding, and in general the staff tended to try and get their relatives to the front of the queue, rather unfairly. But everyone was very friendly and were quite interested in having a medical student all the way from Australia- South Africa or Mozambique would have made at least SOME sense, seeing as Swaziland is such an obscure country.

I used to draw a bit when I wasn't doing any active learning. Just quickly sketching people's heads with my new fountain pen. I got a LOT better, too. The people in Swaziland were overall a good-looking bunch. Even though not all of them are beautiful, they have really even, well-balanced features. There's a surprising amount of variation in looks too, much more so than a place like Sri Lanka, where I guess people are inbred. Heh. So I became quite well-known for drawing, and the patients would jokingly ask to see what I was drawing!

Anti-retrovirals have really changed things for the better. It disgusts me that in the past they weren't available, because to tell the truth, in the current age, HIV is chronic and treatable, like diabetes, rather than a terminal illness. Not giving HIV positive people the drugs is akin to not giving diabetics insulin. I saw many patients who presented, really unwell, and now have their disease under control and are fit and healthy, though possibly suffering from side-effects of the treatment.

So, I saw several patients who were obviously very ill. You can sort of tell who has TB- they're totally emaciated, sweating heavily often. They look very unwell. I saw someone with probable cryptococcal meningitis- head cocked back, blank, staring eyes. The "crypto" look. There was a woman who came in with PCP- a form of pneumonia that people who are immunosuppressed can get. We saw her all the way from getting ill, her admission with severe shortness of breath, to her complete recovery. Babies, fat and healthy once their CD4 counts had recovered (obviously I did not see them all the way from when they were ill to when they improved- I was only there for 3 weeks). Needless to say, it was one of the most rewarding things- seeing that the access to drugs really really helped people.

It was also good to see people smiling and laughing. They don't show you that on the ads of starving orphans. But it's what really gets to you. A sense of humour indicates that there's someone just like you there. Someone who could easily be your mother, friend, son. Even could be you. It was nice to see the doctors and patients joking with each other. It instantly set everyone at ease. Made working worthwhile. Somtimes chilled you with the knowledge of the epidemic.

The paediatric days were depressing and rewarding. Kids with HIV look small and skinny. They lose weight for several reasons- chronic diarrhoea, other infections of the gastrointestinal tract, repeated infections in general, the HIV itself. They gain a lot of weight when they start HAART- highly active antiretroviral therapy. Though usually they are brought by their mothers or come in alone, from school, often a father, grandmother or another relative will bring them in because their mother (or parents) have already died of HIV. Or sometimes the parent doesn't care, for one reason or another (but that is rare). I wrote up several prescriptions to start kids on HAART. This feels so wrong precisely because these kids will have to take these drugs for their entire lives. Usually a combination of d4t (stavudine) which causes bad fat redistribution and peripheral neuropathy (tingling and numbness in hands and feet), nevirapine (NVP) which can cause liver problems and bad drug reactions and 3TC (lamivudine) which isn't so bad at all. Patients on HAART have to have their CD4 counts ("soldier cells"- they regulate the immune system and are what HIV attacks), the amount of virus in their blood, their liver function and other things checked regularly. So you can imagine that there was a huge line purely for taking blood from little kiddies. Who would either scream and cry and fight, which is rather distressing, also because it's quite dangerous because of the possibility of a pricking yourself with an infected needle, or would stand, serious and mute, bravely taking the needle without any complaint. Poor kids. It was heartbreaking.

There was a small girl of about 8 or 9 who I actually first saw in the STD clinic. She was brought in by the childcare worker who she was living with- her grandmother asked her to look after her because she (the grandmother) could not control the situation at home, where one of the older male relatives was abusing her. The girl was this gorgeous, shy kid, who eventually smiled me possibly the biggest smile I have ever seen. She needed an STD screen. She had also contracted HIV, so we saw her again in the VCT for follow-up. She recognised me and was curious about my drawings, so I asked her whether she wanted me to draw her a picture of herself. Grinning broadly, she nodded a yes. So I drew a quick sketch of herself and gave it to her. She seemed really happy =). Later that day in town, she and her guardian saw me randomly and called out to me and said "Hi!". It was a nice feeling.

And incredibly depressing. Chilling. Sigh. Everything that I did was bittersweet.

The ward was also very interesting. I was following Dr PF Dlamini, a Senior Medical Officer (as opposed to Dr D Dlamini who apparently didn't turn up as much), who was Swazi. He'd wanted a job in South Africa but they had told him immediately "your country needs you more". So there he was in Swaziland.

As usual the male ward smelt significantly worse than the female ward. For whatever reason, the male ward, no matter where you are, smells distinctly of stale urine and body odour. It was pretty crowded, similarly to Sri Lanka, and there was the occasional patient who was on a mattress on the floor. Often hooked up to a drip, no less!

90% of the patients on the ward have HIV. A lot of admissions for TB, for example. Tuberculosis is a disease which is hard to catch and doesn't usually cause symptoms in people who get it, oddly enough. As long as they have a healthy immune system that is. The moment that ones' immune system is laid low, especially by HIV, TB can't be contained properly by the body, and it causes disease and can even spread easily outside the lungs, depending on how bad the immune system is faring. People with uncontained TB are also more infectious, for obvious reasons. There was, of course a large variety of patients. While many were suffering from HIV-related conditions, you definitely could not make the assertion that all were. There were several cases of liver failure (for reasons that become obvious later in the piece- drugs, infections, etc). Many admissions for anaemia (likewise). Several stroke patients. Several people with rheumatic heart disease or heart failure- conditions that do not really affect the young in Australia, as streptococcal sore throats are treated with antibiotics promptly. There were even some pretty odd cases- a case of Sydenham's Chorea, a disease which causes abnormal movements following a streptococcal infection, and a case of neurocysticercosis where pork tapeworms end up forming cysts in your brain. So it wasn't all HIV.

There was a patient on the ward who was admitted for severe anaemia. He was in Stage 4 of HIV, and he was only 19 (he looked younger though). He could barely eat because of mouth infections and was pretty hungry. This guy needed a blood transplant urgently. However, because of HIV, and because of the high demand because of severe anaemia, the situation was dire. His life was saved for the moment by the fact that they managed to get him 2 units of blood. But he definitely needed more. He was very week. It was pretty depressing, seeing him. He wasn't much younger than me. He was doing pretty badly. Poor guy. His mother came in every day to see him and help out.

It's interesting, HIV is primarily a disease of the young in Swaziland. There are certainly some people over 50 who get HIV, but the line to VCT is chock-ful of young people, whereas the Hypertension clinic line is full of old people. Yes, they get hypertension and diabetes and heart disease in Swaziland. Not everyone has HIV! More than half don't. However, it's really changed the face of medicine there, given that it is probably the most common chronic condition and has so many effects on disease. You could easily write an entire textbook to go along with the usual Textbook of Medicine and call it the Textbook of HIV Medicine. It would have exactly the same chapters in exactly as much depth and it would be what they use in countries with a high prevalence!

A note: the regimens used in Swaziland are different to those used in the West. Access to drugs is one issue- it depends on which drugs are affordable or donated- and also some drugs are contraindicated because of local conditions. They use nevirapine instead of efavirenz first-line because of the high rate of pregnancy. They use d4t instead of AZT because of the high rates of anaemia- I saw several admissions to the ward per day with anaemia because of AZT suppressing the activity of the bone marrow. Anti-TB treatment also causes issues because TB drugs and antiretrovirals are toxic to the liver. Hepatitis B is also quite common as is the use of traditional medicines, which also have liver toxicity. So I asked Dr Dlamini what he would do if there was a patient with HIV who was on Anti-TB treatment, had suddenly fallen pregnant and had anaemia to boot.

"That woman clearly has severe issues!" was his astute reply.

The other place that I hung out a bit was PORECO- which was a pilot research project in Swaziland on implementing a low-cost intervention to prevent the transmission of HIV from mother to child (vertical transmission). With no intervention, the rate of transmission is roughly 50%. Very high. And due to probably three mechanisms of infection: 1) A new infection in the mother leading to the foetus getting infected; 2) The delivery itself; 3) Feeding from infected breast milk. Until fairly recently with modern interventions, the rate in the West was actually around 5-6%, but now is more like 0%. In the PORECO project, they counselled the mother (and if possible the partner) extensively, monitored her health and progress, gave a dose of anti-retrovirals to the mother and child before/after delivery, and advocated either formula feeding or exclusive breastfeeding with abrupt weaning.

"BREAST MILK?!?!" you must all be crying out by this point. Well... yes. Some preliminary research in South Africa suggests that exclusive breastfeeding (no extra stuff like water or juice or formula) actually has a rather low risk of transmission. Mixed feeding, however, because of increased permeability of the gut, supposedly is what carries this high risk of transmission. Interestingly, the PORECO project supported this finding. Of breast-feeding mothers, no babies who were HIV negative at 6 weeks became HIV positive (suggesting that those babies who were HIV positive probably got the disease during delivery). Why is this all important? Because in many places, including Swaziland, clean water and hygiene can be an issue, and these things are vital if you want to formula feed your child. In fact HIV negative formula-fed babies often die of malnutrition and dehydration secondary to diarrhoea. So, in these settings, exclusive breast-feeding may in fact be worth it because the benefits significantly outweigh the risks. Of course this is all very new stuff, and it remains to be seen whether it is borne out by future research.

The rate of HIV transmission was actually 6-7%, comparable to the old figure in Western countries. Which suggests that the main risk factors are the delivery itself, and possibly some foetuses catching HIV in the womb. It's nice to see low-cost interventions making such a big difference.

It is pretty amazing seeing simple things like drug availability and other interventions making a big difference, and this is what is hopeful about the situation. My cousin has done a LOT for the people here- she set up the HIV clinic in order to try and treat the complications of the disease even though anti-retrovirals weren't available back then, even though people said it was pointless. As a result Swaziland became one of the first developing countries to receive low-cost drugs. So it is heartening to see that in some places at least, a doctor really CAN make a difference. To an entire country, even! It is good to see that even with such poor odds, things are starting to improve. However obviously people are both uneducated about HIV and/or do not care or are fatalistic about the disease. So it is both encouraging and depressing. I think that is a lot of what I felt about my experience, medically speaking. It was bittersweet. Very bittersweet.

I think it is absolutely criminal how slowly the drugs are reaching the people who need them. How little the developed world is doing to improve the factors that make HIV infection so widespread and deadly- provision of healthcare and education and economic conditions and even in some areas, water and food. I also think that we in Australia have no real right to complain about the healthcare system or doctor shortages (unless we're Aboriginal or living in a truly remote area). It is also amazing how much I have learnt in such a short time about medicine and thinking for myself and on my feet, about clinical medicine, and about the ability of people to actually make some kind of difference and have some kind of meaningful effect on society. I've learnt to stop relying purely on investigations and to actually trust my own clinical judgement. I've even helped make decisions and done things I would not have had the opportunity to in Australia.

So I propose something rather unusual. I would like very much for developed countries with good postgraduate training programs to send their registrars to resource-poor settings for a rotation so learn how medicine is practiced over there. To improve their clinical skills, to learn to think for themselves. To see how bad things can get, to start to see their patients as people again. To know what human suffering is. To see that there is a possibility of actually having an awesome and satisfying job where you are valued as a worker. To really help people. I think it would definitely be a mutually beneficial situation for all parties involved- Australia gets better trained doctors, poor countries get more medical staff and doctors get better experience. It could even feasibly be run as an exchange program, if the doctor shortage is a pressing concern.

Whatever it is, there is good work to be done. And I feel like I could, as I said, back then "definitely work here."

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