Re: AIDS/Africa

As we began our morning clinic, a forty-year-old man was carried in by his brother and friend. They propped the man on a bench beside the others, trying to keep him sitting up . . . not for long. The man suddenly slid down to the floor and stopped breathing, died in the waiting room. No screaming or panic here. We carried him into the nearby meeting room where we confirmed his death before brother and friend . . . no resuscitation equipment at the clinic, no protest, just a slowly forming apologetic tear in the corner of the friend’s eye. The patient lay sprawled on his back, fully dressed, legs in open scissors formation, arms slightly outstretched . . . he looked like he had been slain in an old-fashioned gun duel. In Canadian emergency situations he likely would have had his clothes torn off as revival efforts were instituted. His brother tried and failed to do what the nurses normally do at Motebang Hospital, dislocate the temporomandibular joints so that the teeth of the dead do not protrude . . . because the clinic does not have nurses.

Today we were told that only four bottles of a combination arv were in stock and, at our current pace of prescribing, the supply would be done by next week. An hiv treatment interruption—even by hours—can lead to viral resistance and end the capacity of drugs to beat the virus, not only for the individual whose continuity of arvs is broken but beyond, filtering through to sexual contacts newly infected with now-drug-resistant hiv.

January 2, 2005

Never-ending conversations about “sustainability, empowerment, capacity, rollouts” by “expats” (I guess that includes me) who are “in country” . . . I don’t know what any of these terms really mean . . . what does “in country” mean? I disdain censorship but figure it would still be a good idea to ban all these slogans and start all over, forcing an exact enunciation of what people really think without the cover of inexact jargon.

January 5, 2005

Some signs of victorious battles . . . twenty-nine-year-old woman, 46.5 kg , cd4* count of 411 (almost normal) and a hemoglobin† of 9.4 (normal is 12 but this is great for here); my colleague Dr. Bob Birnbaum exclaims “she is rocking” and so she is. Saw in follow-up a twenty-seven-year-old woman who we treated for a presumptive pcp‡ on Dec. 22, then gasping at 48 breaths/minute with an exercise-class pulse of 144/min—now breathing at 16/min and pulse at 108/min. Her hemoglobin, at 7.7, will always give her a fast pulse but as she says, “I can breathe.”

*cd4—The immune system’s critical cells that hiv attacks
†Hemoglobin—Oxygen-carrying molecules of our bodies
‡pcp—Killer aids pneumonia

January 9, 2005

While climbing the 180-metre mountain behind my house this a.m. with Bob and Russell, passing rondavals, gardens, massive aloe trees, cattle in pasture, brick huts, roofs held down by rocks, always greeted by smiles, hellos and some giggles, guided at times by young barefoot boys to the safest path, we were discussing hiv resistance. Bob said if the arvs are not available this week it means resistance, and I agreed it would be disaster for Lesotho and he said “No, resistance for the world.” He is right. Then horrible thoughts came . . . so what, Lesotho dies with aids and without arvs and without resistance, or it dies with aids and with an interrupted supply of arvs and no infrastructure and arv resistance. So what? Matters not to a fifteen-to-forty-nine-year-old generation who will fade away anyway. hiv and hiv resistance could be halted if hiv was engaged as war is engaged. In the meantime Lesotho and the patients we see have nothing to lose, may even gain a few years (which is a lot here and they know it).