Citizen?

Chuma is a nine month old male.  His mother brought him to the hospital because he was having trouble breathing and a fever.  When he arrived he was extremely sick with hypoxia (low oxygen levels), severe respiratory distress, malnutrition and lethargy.  His mother did not receive prenatal care and is HIV positive so his chances of getting HIV are around 50% (since he was also breastfeed, babies who are not breastfed have around a 25% chance of getting HIV from pregnancy and delivery without intervention).  We started him on intravenous antibiotics, oxygen, IV fluids, and steroids, treating him for both PCP pneumonia (a type of pneumonia that occurs only in patient's who are immunocompromised) and for bacterial pneumonia.  We also began a work-up for TB, HIV and started treating his malnutrition.  But his biggest problem is that he is not a citizen of Botswana. He was born here, but his parents are from Zimbabwe and because of that he may not survive.

As I have mentioned before, the Botswana government provides free health care (including antiretrovirals to treat HIV) to all citizens.  However, non citizens are not given the same treatment.  They can be seen in local clinics and hospitals, but they have to pay for each service.  For example, if I want an x-ray for a citizen all I have to do is fill out the paper, of course the machine has to be working and the paper has to make it to the x-ray department, etc so sometimes it takes a whole day, but eventually they will get an x-ray.  If a non-citizen needs an x-ray they have to collect the funds, (around $15 which sounds cheap, but when you make $200/month if you are extremely lucky to have a "well paying job" (many people are unemployed or working "piece" jobs so are not making money when their children are in the hospital) it gets expensive quickly), take the money to medical records, get a receipt and then take the receipt and the form to the x-ray department. 

The biggest problem arises when the patient is HIV positive. Prevention of Mother to Child Transmission (PMTCT) is fairly effective in Botswana.  If mothers follow the complete protocol (complete with free formula from the government) there is only around a 4% chance that the baby will end up infected.  This is, of course, still higher than the risk in the US which is less than 1% chance of transmission for a mother who follows the full protocol.  Non-citizens are not provided with PMTCT or formula so their risk of transmission is much higher.  Once the baby is born they need to be tested for HIV with a HIV pcr test around 6 weeks of age (cost $22) and if it is positive they can be started on treatment right away (the sooner you start treatment for a baby the better the outcomes in the long term).  Treatment has gotten a lot cheaper over the years with the advent of generic drugs but the cheapest treatment for babies is around $35 a month (since the liquid suspensions are more expensive then pills). 

It seems like it would be easy for well meaning doctors and nurses to foot some of this bill, but it is dangerous to start treatment without knowing if the patient will be able to continue because stopping the medications will breed resistance.  It is heartbreaking to watch these children go without treatment, and often die, just because their parents are from a different country.  Of course, I can also somewhat understand where the government is coming from because they are struggling to provide care for all of their citizens as it is, but nevertheless humans are humans no matter which country they come from.  There are a few doctors who have started a fund to support non-citizen HIV treatment, but with the economy as it is, the fund has dwindled to almost nothing.  If anyone reading this would like to contribute to this fund, please let me know and I will give you the details.  For now I hope that Chuma can make it through his acute illness, so that we can try to help his parents afford the testing and drugs that he, most likely, desperately needs.