Disparities

This past week has been quite busy.  I worked at 2 different hospitals and one local health clinic.  The disparities in the care available to patients in the village compared to what is available in Gabarone are striking (not to mention when you compare it to The States!).  Botswana actually has quite a good preventative care model in theory.  Every village has some sort of health facility.  The smallest villages have mobile health posts that are staffed once a week or so by a nurse who travels to the area and does his/her best to provide basic services.  Larger areas have health clinics that are mostly staffed by nurses but medical officers visit about once/week.  Then there are district hospitals that can provide basic hospitalizations and procedures like c-sections.  Finally there are larger "referral" hospitals.  The problem is staffing and transportation.  The clinics are staffed largely by nurses who try their best and refer when things get more complex, but there are no x-rays or lab tests available at the clinics and getting patients to go to the hospital for these services or to be seen by a doctor is hard.  Also when patients are very sick at the local clinics the transportation to the referral hospitals can take too long and many don't make it. 

Even at the district hospitals resources are very scarce.  When I was in Palapye (the town about 20 min from Serowe) last week I saw a 10 year old with asthma who was breathing 70 times/min and really struggling for every breath.  She was in the "paediatric (they use the British spelling here) ward" which consisted of 2 small rooms (about the size of a standard single patient room in the states) each with 4 patients (one of the patients was sleeping on a mattress on the floor and all of the patients' mothers were with them - it was quite crowded.  There was no oxygen in the room and there was no nebulizer machine to give her albuterol which she so despirately needed.  As the "Paediatric Specialist" they wanted my advice.  Well, I thought she needed albuterol, oxygen, steroids, IV fluids, maybe even intubation the way she was breathing, but what was available?  The nurses were actually great once I explained that she was incredibly sick, but could get better with the right medications.  They found an albuterol pump and even a spacer which had been used by another patient, but we cleaned it!  One of them went and got an oxygen tank (of course, then we had to look for a face mask or nasal cannula - there were none to be found).  After about an hour (during which the mother was giving the child 2 puffs of the inhaler every 15 mins) a nebulizer machine was found! We (atcually they) even figured out how to plug it into the wall socket without an adaptor (all the wall sockets here have 3 square plugs and all the appliances have 3 round ones or 2 long ones, so you always need an adaptor for everything.  Unless you stick a pen into the top square plug and jam the two long ones into the bottom holes - or something like that - I use adaptors (don't worry mom and dad ;)).  We did not have a face mask so we rigged up the albuterol, so that the mother could sit with it under the child's mouth.  Then I suggested giving her IV fluids and a dose of magnesium.  There is no way to drip fluids here, and magnesium is supposed to be a slow infusion over 15 min.  So we calculted the amount, mixed it in a syringe and one of the nurses pushed in 1 ml every min for 15 min.  I felt kind of like McIvor.  But several hours later the patient was already sounding better and the next day she was home!

Not every story is as cheery, of course.  In Palapye almost every child I saw in clinic on Wednesday had a detectable viral load.  Basically when you are on treatment for HIV your viral load should be undectable.  If it is detectable then usually you are not taking the medications or have developed resistance (most often from a previous episode of poor adherence).  These children are largely failing because they are not taking the medications and mostly it is because they have no social supports.  Many are orphans living with relatives or in homes for orphans and no one ensures that they take their medications every day.  In Gabarone we have a psychologist and a social worker to help patients and families through these issues.  In the smaller villages there is sometimes a social worker, but usually it is one or two people for the entire hospital and there is not much they can do to change the home situation for many of these children.  Also in the district hospitals it is harder to get labs tests done and returned.  Viral loads have to be sent out and resistance assays (tests to see which medications the patient has developed resistance to.  We use this only when they are failing second line therapy to try and figure out a salvage regimen for them as third line) are taken to Gabarone one day a week.  On Wednesday the CD4 machine was down so none of the labs were being drawn.  All of this means that many of the children I saw had been failing for months and we were still unable to select a regimen that might work for them. 

The local clinic was even harder.  Basically the clinics are a collection of trailers.  The Infectious Disease Clinic (aka the HIV clinic but no one wants to call it that) is usually the last trailer in the back of the clinic.  Yesterday the one computer at the clinic (which provides lab results) was not working, so it was hard to figure out how to manage the patients with no results.  There are no appointment times at any of these clinics so all the patients show up before 7:30 and try to be first.  They end up spending all day waiting to see the doctor, then they have to wait in line again for a nurse to draw blood if they need it (to be sent to the hospital) and finally they have to go to the hospital to wait again in the pharmacy line and get thier ARV (anti-retroviral) medications.  So a visit to the doctor is at least a one day affair - more if you wait until the next day to go and get your medications filled.  It is no wonder that adherence is an issue.  And despite all this the vast majority of people are incredibly adherent to their medications (studies have shown that people in Africa are more adherent than those in the States.  I think it may be because everyone here knows someone who died of AIDS and they know that taking the medications is the only way to survive.) 

These are some views of one of the local clinics.  On the left is the waiting room with the 2 consulting rooms on either side.  Picture this filled with 70+ people waiting to see the doctor!  On the right is a bad picture of the trailers that make up the clinic.  (I was trying to be inconspicuous)

I don't want this post to be a total downer so I thought I would end with a picture of the beautiful sunset that I can see from my house every night.  The stars are also incredible. 

And here's one of the horses that often hang out right in front of our gate.  On some days there are donkeys too.  I'm not sure who they belong to, but they seem to know thier way home at night.