A Day in the Life

Sorry for those who are not medical, but I will try to explain some of the more medical terms....

Each day at the Botswana-Baylor Center of Clinical Excellence (or the COE, as we call it) begins at 7:30 with a prayer.  There are no appointment times; patients are just given a day to return and most show up around 7:30 (which often means they have gotten up hours earlier to travel from their village to the city).  The clinic staff (nurses, receptionists, pharmacy techs, translators, social workers, medical assistants, janitorial staff, doctors, etc.) gathers in the lobby, facing the patients, and begins to sing.  They sound like a professional choir, (for all those concerned, I sing very quietly or mouth the words to the songs I know).  Usually the songs include "Kumbaya my lord," some songs about Jesus, and songs in Setswana.   At the end, there is a prayer in Setswana.  It is a wonderful way to start the day with the songs filling the lobby, the building, and spilling out into the parking lot - giving hope  and offering support to all of our patients. 

Around 7:45 or 8 we see the first patients.  Today I saw some great success stories and some challenges.  The first patient I saw was a 16 yr old boy who came alone.  He was very energetic and doing excellent with taking all of his meds = 100% adherence!  He stopped in the middle of the visit to return a text message, and when we were done stood in the hallway with his cell phone on speaker so everyone could see how popular he was.  When I asked if he would be joining us for Teen Club this Saturday he said maybe but he had a number of things to do and wasn't sure if it would fit into his busy schedule.  His viral load is undetectable and his CD4 (cells that fight infection) are as high as person without HIV.  All that has been achieved, and he is still on first line therapy (meaning he has never become resistant to his medications - which usually happens when patients don't take their meds). 

Then there was an 8 yr old boy who had been doing very well on therapy for serveral years until 2006 when his mother stopped bringing him to clinic, and hence stopped giving him his meds.  The clinic staff tried to track him down, but to no avail.  He returned last month because he had lost a lot of weight (he weight was that of a 5 yr old, as was his height), had a chronic cough, night sweats, and fever.  He was admitted to the hospital and started on treatment for tuberculosis.  His mother, who also has HIV, had been faithfully taking her medicine (which she got at a different clinic), but had not brought him to see a doctor for three years.  She said it was because she did not have money for transport.  Today she brought back only one of the medications he had been given in July (mutivitamans and cotrimoxizole (or bactrim for those in the states) to prevent infection in those not on treatment for HIV).   His adherence on that was 76% which is not sufficient for being successful on ARVs (antiretrovirals).  Clinically he needs to start on medications, but we can't start medications if he won't take them, because he will develop resistance and be out of options.  Luckily we have an "in-reach" team and the charge nurse had a long talk with mom.  The team will go out to the house on Friday and assess the situation, do some education, and determine if the family can qualify for transportation assistance.  Hopefully, we will see him again in 2 weeks.  Hopefully by then, he and his mom will be ready to commit to treatment.

And then there was the 10 yr old severely developmental delayed boy who lives in an orphanage (both of his parents died many years ago, presumably from AIDS).  One might think that living in an orphanage would be good as far as adherence since he is taken care of by "professionals," or at least people who have received more training than most.  However, often the orphanages are understaffed and there are so many changes of caregivers that they forget to give the children their meds.  This child's viral load (amount of HIV in his body) was sky high (it has never been suppressed).  He was on "salvage" therapy - basically he has developed resistance to many of the medications available in Botswana.  So we send a resistance assay (a test to determine which drugs his HIV is resistant to and which are still options).  This test is done routinely in the states, even on patients who are on first line therapy.  But here we reserve it only for the most challenging patients, and we are lucky to be in one of the few countries in Sub-Saharan Africa where the test can be relatively easily done (though it takes at least a month).  He was again failing the therapy that had been created based on the last assay, so we had no choice but to send another resistance assay, stop all medications, and once again send the in-reach team to the orphanage to see if they could figure out the adherence problems.

Those were just 3 of the 10 patients I saw in the morning.  We finished at 1:30; I took a small break to eat a PB+J sandwich and made my way over to the main hospital for "general peds clinic."  Since there aren't many pediatricians or even family doctors in this country, most patients are seen at local clinics by nurse prescribers (kind of like Nurse Practitioners, only with less training) or medical officers (people who have completed medical school and one year of general internship (a little of each specialty) and then go into practice.)  When there is a pediatric question, they are referred to the nearest pediatrician.  As there are not any pediatric neurologists, nephrologists (kidney doctors), cardiologists, etc in the country we "general pediatricians" become instantly upgraded.  I saw several children with Cerebral Palsy and Epilepsy and managed their seizure medications.  I saw a child with steroid resistant nephrotic syndrome and started her back on cyclophosphamide (sorry non medical people - can't really explain all that).  I saw children with severe developmental delay and speech problems and sent them for hearing tests and speech therapy (luckily we do have speech therapy).  And even one that I really knew how to tackle - a 3 week old with breast buds which were already getting smaller = normal!  Basically in one day I have been upgraded from a general pediatrician just out of residency to an HIV specialist, pediatric neurologist, pediatric nephrologist, and developmental pediatrician (to name a few).  Luckily I have some of the more seasoned PAC doctors around to offer consults, but in an environment without as many labs, x-rays, and other diagnostic tests as we are used to; we are often treating blindly and following closely.

If you are still reading, and wondering how patients pay for all of this, you will be surprised to know that it is completely FREE!  The Government of Botswana (with revenue from the diamond mines (that they were smart enough to own), 10% sales tax, and 25% income tax on the weathly, pays for it all!.   This includes doctors' visits, meds, tests, and even transport to and treatment in South Africa for things, like cardiac surgery, which are not yet available here.  I say it is worth it!  And it is certainly nice not to have to fill out insurance pre-authorization forms, billing sheets, or check insurance formularies.  (Yes, you do have to check the Botswana drug list, but it is just one list for everyone and a surprisingly complete one!)

I saw a very enlightening piece on this theme from PBS (one place that allows you to watch their videos outside the US - boo to netflix, hulu, and amazon).
I recommend it to you all: http://www.pbs.org/moyers/journal/07312009/watch.html