|Too Young to Die (Zambia Educational Publishing House, 1992, 56 p.)|
Rebecca was a different kettle of fish. She was brought in by her mother, the history being that she had started behaving strangely a week before admission. Prior to that, the mother had noticed that Rebecca had been losing weight and being well-read and educated and in full knowledge of her daughter's modus vivendi, she had plainly told her that she probably had AIDS. The girl had refused to come to hospital till that evening when she had been forced. When Rebecca came in, she had to wait for quite a while before I could attend to her as I was alone that evening covering for one of the junior doctors who had a crisis in her personal life. The mother gave a very good history, telling me plainly that her daughter was a prostitute and that she feared that she might have AIDS. She said she had failed to control her daughter who had become 'wild' in secondary school, abandoning her education in Form Two and picking on the life of a 'good time' girl. The mother said she was widowed and raising six children on her own had been next to impossible, compounded by the fact that four of her daughters had become pregnant out of wedlock. Rebecca had 3 children from 3 different fathers and all the children were being kept by the grand-mother.
Rebecca had been living with some friends but when she started feeling unwell she had moved in with her mother. The girl had obviously lost some weight, was quite confused, febrile and had neck stiffness suggesting meningitis. I did a lumbar puncture - getting fluid from the spinal cord - and this was not clear fluid, further supporting the diagnosis of meningitis. I then went back to the mother whose first question was: Was it AIDS?' She was a refreshing, different woman, the mother that is; frank and to the point. I told her that I was not sure then, and I could tell her more after doing some more investigations, but meanwhile I had started her on treatment as it seemed that she had meningitis. Two days later the results came back and by then Rebecca had been moved to the main wards. She was HIV positive all right and she also had a fungal meningitis, cryptococcus, which commonly occurs in people with depressed immunity, like AIDS patients. I told the mother about the result and though she was not surprised she was nevertheless upset because she told me that she had warned her daughter on many occasions to change her ways, but to no avail. How long was her daughter going to live? she asked. Well, I couldn't answer that and told her so. But I explained that we could treat her present infection and her daughter could recover almost completely, but nobody could tell when she would get another infection or a recurrence of the old one. We started Rebecca on the appropriate drugs and she made a remarkable recovery. Within three weeks we were able to discharge her. Unfortunately Rebecca had a relapse about a month later and was again admitted to hospital. Apparently the meningitis hadn't been eradicated and she died after about a week in hospital.
Prostitutes, commercial sex workers or whatever you choose to call them are in real danger of extinction because of AIDS. Positivity rates for HIV are in the range of eighty percent or more in most studies in Africa. Successful trials have been done in some cities where these girls have received extensive health education on AIDS and financial support has been provided to lure them from prostitution to small-scale industries. Health education alone has not been very successful in stopping the practice because of the easy money and the desperate financial straits of most of these women. Studies do indicate that more and more prostitutes are favouring the use of condoms, but it may be the case of closing the barn door after the horse has bolted for most of them. The oldest profession is at present also the most dangerous.
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We see a lot of deformed people at hospitals and most of us have developed a style of looking at these patients without staring. Most of these patients are probably used to being stared at everyday, but I am sure, they don't expect doctors to do that as well, unless they have come to the hospital because of that particular deformity. Their deformity of course does not make them immune to the diseases that 'normal' people have, as was the case with Marjory who was about 24 years old and had suffered from a condition called cancrum oris or Noma as a child. This disease eats up practically both lips and sometimes part of the nose so that when you look at the face, it's like there is a hole in the centre.
In fact there is a hole in the centre of the face. The disease is due in part to malnutrition and a bacterial infection, and it doesn't leave a pleasant sight at all. I normally look such patients straight in the eye all the time, unless there is need to examine their deformity. It seems to put them at ease. Marjory was admitted with a history of diarrhoea and weight loss of about one month's duration. I can't recall now if she was married, but she had a child of about one-and-half-years of age who was still on the breast. On that day of admission as on many other days, we had to practise a triage of sorts because of the critical shortage of beds. I had to decide who was sick enough to warrant admission to the main wards and who was well enough to go home. Marjory fell in the latter group and I asked her to come back the following week to our clinic, after taking blood for some tests, including one for HIV. She never came to the clinic. About a month later I found her readmitted by another unit. Needless to say I recognized her immediately and took over her management. She had come in with the same problems as before, weight loss, diarrhoea and fever. She told me that she had been unable to come for review because just before she was due to come, she had fell too ill to make the long journey.
We gave her some antidiarrhoea treatment including a drip and did some more investigations. A few days later her blood results came back: HIV positive. I remember thinking, unreasonably I suppose, that it seemed so unfair that with her gross deformity she would also have that dreaded virus coursing through her veins. The fact is anyone exposed to one of its modes of transmission is a candidate. The good, the bad, the ugly, the old, the young, the rich and the poor, the famous, the popular, the unpopular, the important and the nonentities; anyone...
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Diseases which had previously been considered rare were becoming more common. Other diseases like Tuberculosis were becoming more frequent and more fulminant. We were taught at medical school that the commonest causes of pleural effusion (fluid in the chest) in Zambia were: 1. T.B. 2. T.B. 3. T.B. 4. T.B., the other causes coming after that! Of course this was merely to emphasize the point that we should consider common things first. The fluid collection was usually not a serious form of T.B. and practically every patient made a full recovery, but in patients who also have the dreaded virus, we have been seeing very serious forms of T.B., sometimes even bizarre presentations. But it was not only in tuberculosis that we were finding strange, bizarre and puzzling presentations of diseases. The whole game seemed to be changing and some organisms which had hitherto been regarded as harmless were having their status re-examined because, in patients with severely reduced immunity, no one was sure if these agents could not become pathogenic. All this is leading to a situation where the texts of many of our expensive medical books will have to be re-written, at least in our part of the world. Roughly 60-70% of T.B. patients have HIV infection as well. In the other patients who are free of HIV, T.B. can still mimic AIDS, making the situation complicated. The combination of T.B. and HIV infection is fraught with management headaches, the most frustrating being the frequency with which these patients have drug reactions. In the HIV era, it seemed as though this old adversary had acquired a new face; a murderously new face it was.
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Consider Laiti Banda, a young man of about 20 years of age. When I first saw him he was very breathless and I made a diagnosis of fluid on the whole left side of his chest. A chest X-ray was done and this showed that in fact he had fluid on both sides of the chest and a very large globular heart. He gave a history of having stayed with his mother who had suffered from T.B. but was by then cured. I had him transferred to the main ward where I did a chest aspiration and removed close to one-and-half litres of blood-stained fluid from the left side of the chest and half a litre from the other side. This made his breathing much better and I then asked a colleague to do a special examination which confirmed my suspicion that Laiti also had fluid around the heart, though this was not causing him any distress at that time.
The results of the chest fluid analysis suggested tuberculosis as the cause of the blood-stained fluid and appropriate treatment was started. I have seen quite a number of patients with blood-stained fluid in the chest which seemed to have been caused by T.B. and all of them had been HIV positive, though a few had turned out to have the fatal Kaposi's Sarcoma. I saw Laiti the following day and his condition had deteriorated and he showed signs that the fluid around his heart was causing problems, constricting the heart and restricting its contraction. He was badly distressed, restless, sweaty and apprehensive. I had him transferred to the Intensive Care Unit (I.C.U.) where I removed about half a litre of blood-stained fluid from the sac around his heart and this relieved his symptoms dramatically. I instructed the I.C.U. nurses to keep him for about an hour under observation before transferring him back to the main ward. Just as I was about to leave, Laiti called me and asked me to give him his shirt which had been hung on a chair next to his bed. I gave him the shirt and he took out some paper from one of the pockets. Among the paper was a K20 note which he extended to me and said I should buy myself a drink! I had about K400 on me as I had passed through the bank that morning, all in crisp and new twenty kwacha notes, twenty of them and there was this patient giving me his only money as far as I could see! He said he was very grateful, as he had thought that he was dying. I told him that I had been trained to save lives and that I was paid for it anyway, but he insisted that I take the money. It was tricky I tell you (for me anyway), because I did not want to take his money but neither did I want to offend the boy by seeming to spurn a gift. I asked for a compromise: 'Why don't you buy me a drink when we discharge you from hospital?'
'What if I don't get out alive?' he asked. I told him we would all do our very best to make sure that he went home and bought me that drink. The nurses later told me that I may have disappointed the man or made him feel that the K20 was perhaps too small. I don't know what he felt, but I knew that I did not want to get any money from him. It's a situation I had faced before and I am sure other Government doctors must have had the same dilemma, though I doubt if it's a dilemma, to everyone. How to convince a grateful patient determined to give you something that you don't want to get without offending him can be tricky. Yes, I know you are probably thinking why the hell not take whatever is offered? Well, I can only say that accepting any form of gratification from patients for a job I am paid to do is morally unacceptable to me. Fortunately it's a habit which seems not to have caught on among doctors in Zambia despite the unfavourable economic climate. I remember talking to same colleagues from a neighbouring country at a medical conference who told me that their government salaries were so low that they survived because of the largesse of patients! I told them the situation in my country and they couldn't believe me for in their country every patient had to part with something in order to receive the best treatment.
To get back to Laiti, I must say he was a very likeable co-operative and stoic patient. He went through a lot of suffering, but nobody heard him complain, whine or show self-pity. A few days after the I.C.U. incident, Laiti became breathless again and a chest X-ray showed that the fluid had reaccumulated and I tapped both sides of his chest again, removing about 1 litre of fluid. His HIV result came back as positive. A week or so later, I had to remove some more fluid from his chest and from around the heart again. He was not getting any better despite the treatment. We then reconsidered our diagnosis and thought of cancer, but a search for that was negative and there were several factors which pointed to T.B. being the cause of the fluid collection. Besides, you also now know the four commonest causes of fluid collection in the chest.
One morning about one month after admission, I found out that Laiti had died during the night. The whole team was sad because everyone had put in a lot of effort to try and save his life. I have seen a lot of similar cases since then, and I am bound to see some more, all usually very young men or women. It's painful, saddening and frightening seeing them die. Needless to say l never did have that drink with Laiti, and once again, our very best was not good enough.