As with any hospital or clinic, there are busier weeks then others.  During the past week, despite my best effort to discharge patients from the ward, more and more patients crowded in until every bed of the Female ward, entry way, veranda, and side room were filled.  The majority of the cases were fairly serious or at least complex, all requiring more than an easy diagnose and treat plan.  Additionally, I decided to use my hour of the physician group meeting this week to discuss chart documentation and operational improvements, so I was motivated to use my best handwriting and comprehensive note writing.  Unfortunately, while all the other wards were enjoying a low or normal census, I think there were upwards of fifty women to see and make a plan for.  This occurred between the hours of 0800 and 1300 every other morning.  I’m also charged with a continued care ward of 24 additional men and women who I am to see once a week or so, also using my best handwriting and documentation skills and constant teaching to set a good example and make my time here have the most impact.

The wards took up the majority of my time, free and otherwise, but on the non-rounding days I was asked to step-in for a few absent providers in the ART (HIV) clinic.  This is a growing sector of outpatient care dedicated to keeping the HIV population enrolled and healthy, in a highly specialized setting.  On my prior visit, the HIV patients were seen on several days a week out of the same room as the outpatient department clinic patients.  In the past year, a new building dedicated to HIV positive health was built, special files and specialized software, dedicated staff, vehicles and computers are now decades ahead of the rest of the hospital to manage the devastating epidemic that is still sweeping the sub-Saharan countries.

My first clinic day at the ART clinic was intimidating.  There were not enough translators for myself and the two other clinicians (a Zambian medical resident doing an elective from Lusaka, and a senior clinical officer).  Since there are so many languages in Zambia, many of the patients need help speaking the local Tonga language.  Additionally, not to state the obvious, but I’m neither an infectious disease specialist, outpatient physician, nor a pediatrician, so I was a bit overwhelmed by the experience.  With only three days of operation per week at Macha and two days of regional village visits, Tuesdays are the busiest days, and my intimidated mounted as I had to fight through a mob of patients to get into an office to start my work.  In the initial years of HIV care in rural Zambia, patients were very reluctant to come for HIV testing and care.  Many people died, this was described as a “time of many funerals.”  In the past several years, the community decided that too many have died to stand idly by, that their only choice was to come for treatment.  And then they came. 

The Tonga people have a fairly structured and close knit community, but for an outsider, it takes some getting used to.  Many of the men have several wives, and the wives have four to six children each.  Most people live with and remain very close with their parents and siblings, as well as the children of the siblings.  An HIV diagnosis can result in divorce, temporary separation, death of parents and spouses, and other complexities in this community structure.  As with any medical interviewing, you only receive the answers to questions you ask, so a translator is really important in working out the fine details of the relationships of the many people that flock into the room together.  Even more importantly, all women under age 40 have small bundles tied to their back: a baby who may or may not have acquired the HIV virus from her mother.  

Only a small portion of the population can afford to buy premade food such as bread, and a small portion of those people can afford formula for babies.  This means most babies are breast fed up until 18 to 24 months regardless of maternal HIV status, as otherwise they would simply not survive.  Women who are unable to breast feed for various reasons attempt to use cow milk or peanut milk in months old infants, resulting in malnutrition, diarrhea, and developmental delays.  The WHO recommendation for women in such impoverished areas is to breast feed without interruption while taking HIV medication treatment which can prevent transmission.  The babies are also enrolled and maintained on daily ARVs while breast-fed, then later tested to know if they have HIV or if they are safe until potential exposure later in their life.  The estimated burden of HIV ranges from 12% in the rural areas to 30% or higher in the city centers.  The extent of immune deficiency at time of diagnosis limits the ability to start HIV targeted medical management since the patients may be too sick to start a anti-retroviral regimen. Their survival is threatened by opportunistic infections such as cryptococcal meningitis, pulmonary and extra-pulmonary tuberculosis, toxoplasmosis, severe anemia, severe wasting, Kaposi’s sarcoma, cervical cancer.  Despite the grimness of all of these facts, the number of patients who first presented deathly ill and are now recovered enough to work in the fields to feed their family, are working in clinics to educate their fellow Zambians, and are taking care of other’s children orphaned by HIV, is inspiring and motivating for me as I faced the day.


Everyone piles into the Land Rover for the 40km voyage to the regional ARV clinic

Loading and unloading leaves no room wasted on the vehicle

I admitted the first five infant patients I saw in clinic to the hospital, and then decided I was going to stick to seeing adults and let the pediatric experienced physicians handle the humans aged 5 and under, since there were well over 100 people to see and that would make me much more efficient at my job.  The first day turned out to be very long with only a short lunch break; I saw over 50 fairly complex patients with much more going on than just HIV.  After several more days of clinic, once I became more comfortable with the medical management of adult HIV outpatients, I was asked to go on a trip to a regional village ART clinic with the staff.  The number of patients requiring anti-retroviral testing and therapy is so high and the area covered by Macha Mission Hospital spans up to 100km in any direction, there are now several monthly satellite clinics held by an outreach group from the hospital.


At least three patients per bicycle gives a quick count of our patient load today

On Friday morning, I joined 13 people as we stuffed ourselves into a Range Rover, piled medications and lab supplies on the vehicle roof, and went on an off-roading adventure to a town 40km away.  We anticipated 70 to 90 patients, but well over 100 came.  Many humans and bicycles crowded around the clinic; stray chickens and hopeful dogs patiently awaited a scrap of food to be tossed their way.  While getting set up to see patients, I noticed small children repeatedly running by me.  They would run by, turn around, hide in bushes, hide behind each other and emphatically point at me.  To them I look ridiculously pale.  Sitting in the van with the nurses, nursing students and phlebotomist, I noticed again, the car surrounded with little cheerful faces, jumping up on one another shielding their mouths in disbelief.  This was amusing to no end for me.  I live in a very culturally diverse world where few physical features would as much as result in a raised eyebrow.  Here, I am an anomaly, a minority of sorts.  A strange and valuable moment I had already forgotten from my last trip.


Patients being patient

The rest of the day was spent working through the enormous group of people who greeted us in unison when we arrived.  These are hard working farmers and their children who have been losing weight during the hot spell that has killed their crops.  The reality shows such as Survivor and Big Brother attempt to depict life in the raw, where losing means not eating or having to do some “hard chore.”  This land is the real-life Survivor, where food and water run out, people lose their life and limb to accidents and trivial infections that are not treated or not treated correctly.  There are only a small number of health professionals that are widely spaced in the bush villages.  It may take years to understand and incorporate into the world here, but all we do here is by choice. Our reality is that we can evacuate if it gets too difficult for us, but those that live here must cope with the world that meets them daily.  The doctors, nurses, interpreters, clinical officers, hospital staff, and patients welcomed me to Macha, teaching me their language and culture in return.  And for this I am grateful.