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Infectious Diseases in Clinical Practice:
doi: 10.1097/IPC.0b013e318162a980
Reflections of an ID Specialist

In Search of a Miracle

Louie, Ted MD

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University of Medicine and Dentistry of New Jersey, New Brunswick, NJ.

Address correspondence and reprint requests to Ted Louie, MD, 579A, Cranbury Road, East Brunswick, NJ 08816. E-mail: tedlouie@msn.com.

Dr Amisha Malhotra was running late. Breathless, sweating, she burst through the hospital doors and made her way down the hallway, where the medical team was already assembled for morning rounds.

"Rhinos!" she said briefly, trying to catch her breath. The team nodded in understanding. She had been driving to the Hlabisa Hospital in Kwazulu-Natal Province (KZN) when she encountered 2 rhinos in the middle of the highway. Slightly scared yet fascinated, she watched as the enormous, powerful beasts played contentedly in the morning mist, bathing themselves in a puddle, oblivious to the traffic they were so thoroughly obstructing. During orientation, she had been instructed not to aggravate them, and so she was forced to wait until the rhinos had had their fill of the puddle and finally lumbered away.

Kwazulu-Natal Province is located in eastern South Africa, adjoining the Indian Ocean. Although the capital city of Durban is thoroughly modern, the interior is certainly Zulu country. This is the land of the famous 19th century warrior Zulu Chaka Zulu, a land of wild, rugged beauty. Driving through the countryside, one encounters lush, grassy plains, and rolling mountains, underneath great billowing white clouds in an endless blue sky. There are lime and mango trees and beautiful flowers. One can spot monkeys climbing the trees, rhinos cooling themselves in the stream (when they are not obstructing highway traffic), and elephants, giraffe, zebras, and impalas in the tall grass. There is also the constant threat of snakes underfoot. Small villages dot the plains, with round homes topped with tin or thatched roofs.

Despite the beauty of the place, there is also a desolation and loneliness here. The people are desperately poor, and the unemployment rate is high. The rates of HIV and tuberculosis are among the highest in the nation, and an unsettlingly high proportion of the tuberculosis is extremely drug resistant.1 Malnutrition is also a huge problem. Most people here do not live to a ripe old age, and KZN has more orphans than it can handle. It is not unusual for a newly orphaned child to be discovered sleeping at the local bus station. "I think God has forgotten us," mused one local.

However, the Zulu are a proud people with a long history of fighting adversity. Many cling to the ways of the traditional healers, with their mysterious pouches filled with powders and bones. However, an increasing number of people are turning to the modern health clinics for their care.

Dr Malhotra and her colleague, Dr Patricia Whitley-Williams, are pediatric infectious disease attendings at Robert Wood Johnson University Hospital in New Jersey. In 2006, they were given the opportunity to observe and work at the Hlabisa hospital in KZN, as well as at surrounding medical clinics and mobile medical units, for several weeks.

The Hlabisa Health district covers some 220,000 people. Despite the district's formidable health problems, there has been progress made. The Africa Centre for Health and Population Studies, funded by Wellcome Trust, is working on large epidemiologic surveys, gathering useful information on nutrition and disease. Other organizations such as the Bristol Meyers Squibb Secure the Future Foundation and the Elizabeth Glaser Pediatric AIDS Foundation have provided preventative HIV care and community-based care.

On the preventative side, there have been great efforts to promote abstinence and safe sex. Billboards continually remind people in both English and Zulu that "HIV sleeps around" and "ABC. Awuzuthibe ungayi ocansini. Bambelela kumlingani wakho. Cabanga sebenzisa I-condom" (ABC: Abstain. Be faithful. Condomize. Contact the AIDS helpline). Hundreds of condoms are distributed free of charge. Clinic workers put up handmade posters on a variety of subjects, including HIV testing.

A slowly growing network of clinics and mobile trailer units provide blood tests, counseling, nutrition, and medical care to thousands of residents. There is a limited formulary of 9 antiretrovirals. Rapid HIV tests can be done on site. There is a complete blood count machine that does not always work. CD4 counts can be obtained, but other tests such as viral loads and sensitivity of tuberculosis strains cannot be done routinely. Most patients are sent home with bags of fortified porridge and beans. Mothers are sent home with supplies of formula, which they feed to their babies with tin cups.

Accessibility continues to be an issue. The residents often must travel for hours to get to the clinics. The clinics themselves are staffed mostly by nurses, but clearly, there are inadequate numbers of physicians, counselors, and pharmacists. When the trailer is crowded, the stench of human sweat becomes powerful, and many patients must wait outside. They sit on top of crates or cardboard boxes in the stifling, dusty heat, or sometimes in heavy rain. For the most part, they bear their burden with patience and resignation. Sometimes after waiting for many hours, they are told to come back the next day.

The hospital in Hlabisa also is understaffed. Its beds are filled with patients with kwashiorkor, pneumonia, and HIV-related illnesses such as cytomegalovirus retinitis, Pneumocystis jiroveci pneumonia, and lymphoid interstitial pneumonitis, which are now uncommon in the United States. Some of the kwashiorkor victims look like severe burn patients, with desquamated skin and significant anasarca. Some are so weakened that they are afflicted with maggots. For those with severe fractures, the orthopedist is flown in by the Red Cross only once a month. Other times, inexperienced house officers may be guided by attending surgeons over the telephone.

Even so, those children who were recovering from their illnesses never failed to cheer up my colleagues. They often shadowed the physicians, giggling and joking, eyes wide with curiosity. Dr Whitley-Williams gave them hard candy and stickers, which the children happily shared among each other.

Although the obstacles seem insurmountable, there is cause for hope. Only 4 years ago, few people in government were acknowledging the extent of the HIV problem, and no one in the district was on antivirals. By 2006, approximately 800 adults and 80 children had been placed on highly active antiretroviral therapy, and by now, that number has risen significantly.

The challenges ahead are enormous.a To succeed, there must be continued sustained efforts in the following areas: (1) health education, including the promotion of safe sex, the understanding of treatment, and the need for follow-up of HIV, tuberculosis, and other diseases; (2) health infrastructure, including sustained efforts in data collection, adequately staffed clinics and hospitals, and the resources necessary for adequate follow-up of patients; (3) adequate supply and delivery of nutritional supplements and medications including antivirals, antituberculous drugs, and antibiotics and ready availability of condoms; (4) an adequate social and economic infrastructure and social safety net to break the circle of poverty.

Only a completely coordinated plan, well-funded and staffed in all sectors, will have a positive impact. The plan must be practical and effective and must fully take into account local traditions and customs. It must be carefully coordinated and embraced by local government and community leaders. An incompletely executed plan will certainly leave undesirable gaps in care, with possibly disastrous consequences: for example, less than optimal treatment of HIV and tuberculosis could very well lead to a worsening problem with drug-resistant strains.

Does the world have the resolve necessary to control the HIV epidemic in Africa? Perhaps the following anecdote should give us hope. One day, as Dr Whitley-Williams was about to leave the Africa Centre for the hospital, an employee politely asked if he could catch a ride to the hospital to see his baby. His child had been admitted a few days earlier, and the employee had no transportation. Dr Whitley-Williams drove him to the hospital. Father and child were briefly united, but the baby died of pneumocystis pneumonia within half an hour.

This occurrence was shocking and disheartening. And yet, the health care worker doggedly continued to carry on at his job, wholeheartedly convinced that he was going to be part of the health care solution.

Along with many others, he hoped that this was the very beginning of a true miracle.

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REFERENCE

1. Gandhi NR, Moll A, Sturm AW, et al. Extensively drug resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet. 2006;368:1575-1580.

aChallenges; general infrastructure: economy, transportation, education, social services if life expectancy goes beyond 47 years. Health infrastructure: prevention of HIV; vaccines; nutrition; treatment of STDs, adequate counseling for those who take medication, follow-up to insure compliance and minimize resistance. Use of viral load. Combating tuberculosis (comment on XDR TB in setting of resource-poor country). Sustained, committed efforts. Cited Here...

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