9 May 2010

Dear Friends,

I promised to tell you about the hospital. Let's start with measles.

About a month before I came, there was a measles outbreak. By the time I showed up in the pediatrics ward, babies were presenting with the sequelae of measles, namely pneumonia and skin ulcers. If a child survives measles infection, she has severe malnutrition because her gut sheds so much of its outer layer that it can't absorb nutrients from food. The malnutrition leads to poor immunity and infection. Several of these babies had black teeth, the worst tooth rot I have ever seen. (I thought I had seen some pretty rotten teeth among the homeless of Worcester.) It's a stark contrast to the teeth of most adults here; for some reason, most adults here have very clean, even, square white teeth. I wonder if the chlorine in the water acts like fluoride. In any case, skin breakdown occurs and subsequent infections. One little baby, just a few months old, had open ulcers on his groin and laid on his back, breastfeeding and crying from the pain, for days.

Measles outbreaks do occasionally occur at home, but generally they occur in patients who have traveled and are not vaccinated. The Liberian government has recently done measles and polio vaccination and deworming campaigns for child health. I happened to catch a ride one day with some of the health workers who came out to administer the campaigns from Monrovia. They have a difficult task: they ride through the bush on dirt roads to find people who live in small clusters, hardly even villages, in the middle of the bush, to vaccinate them. I sympathize with them. In my small experience going out with our accompaniers to try to find, or “trace,” lost patients, I was often at a loss for what to do. I would arrive at a village in the late morning, only to learn that the person we were looking for had gone “to the farm,” which was an unidentified distance away, likely through narrow trails in the woods. I gave up easily. But these vaccination teams are supposed to go and find every child, in a place where there are no records of how many children there are, no birth registries, no compulsory schooling. Furthermore, many vaccines require several administrations over months or years. It's hard to keep track of the vaccine schedule in the US, where kids are carted to the doctor's office by their parents. Going out to locate them in the forest to vaccinate them, and to ask their parents to keep their vaccination records, sounds like a logistical nightmare. With these challenges, it's not surprising that there are outbreaks of measles. Although, unfortunately, I hear that the vaccination teams also fudge their numbers to make it look like they've reached more children than they have.

Compulsory, free education, linked to vaccination, would probably be the best prevention for measles (and all the other vaccine preventable diseases), but I wonder if anyone in the health sector is advocating for it. In general, the notion of compulsory free education is a wild idea to most Liberians I have spoken to. One 26-year-old asked me, “Does anyone in the US graduate high school by the age of 18?” I thought he was joking. But he had graduated at the age of 24, which is not abnormal. I have met 18- and 20- and 22-year-olds who are in seventh grade. They have to pay their own way through school, so they stop and start as money is available. The poor education reveals itself in small, surprising ways. I've been teaching sewing classes to the women's group, and the difficulty they had holding the scissors reminded me that I learned even that simple skill in preschool.

Sorry for the education tangent. Returning to the hospital, malaria: Malaria is by far the most common diagnosis in the hospital. It's so common that patients come in telling you that they have malaria, and it's like pulling teeth to get them to actually state their symptoms so the clinician can decide for him or herself the patient's diagnosis. Malaria is potentially life threatening in both children and adults. But the pediatric cases I've seen stand out as particularly hard. I watched one 5-year-old die from malaria, her lungs full of fluid. Her breaths slowed to two per minute as the staff tried to find IV access and failed. Her parents wailed and ran down the hall when she died. I met a 3-year-old with cerebral malaria. He had the peculiar history of getting a generalized muscle rigidity every time he had a fever. I saw him over several days, with stiff legs and pointed toes, like a frozen ballerina. His head was turned to the side, and his arms were up and flexed in a fencer's pose, a primitive reflex indicating brain involvement. He whimpered and spoke to his mother through tense jaw muscles. He was treated for tetanus and malaria. He did not respond to the tetanus anti-toxin, but did slowly to the malaria treatment.

Typhoid: Typhoid has a vaccine, but it can be overwhelmed by “large inoculum,” a.k.a. eating a large amount of Salmonella typhi in one go. The available vaccines also don't protect against Salmonella paratyphi, the other causative agent of typhoid. So the vaccine doesn't work that great. It is not routinely administered, and there are trials to develop better vaccine so that ideally, it could be routine where needed. (I had to check my own vaccination record to see if I had been vaccinated. Yes, two years ago, but only because I went to Brazil.) Typhoid is relatively common here, which is unfortunate because it is spread only through poor sanitation. There is nothing unique about a tropical environment that facilitates it. It is only helped by a lack of running water and handwashing, pit latrines, and cockroaches to spread the germ between latrines and the breakfast plate. One patient I saw with a possible typhoid had a stomachache and a taut belly, tight as a drum. Tapping on it, it sounded clearly full of air, so much so that it was pushing up toward his lungs, making it difficult for him to breathe. If his air-filled stomach was indeed caused by typhoid, then he was at risk for perforating his bowel. In order to reduce his perforation risk, he was given an enema. I never found out what happened to him, though, because the next day on rounds, he was gone. He had left the hospital overnight, against medical advice.

HIV: Philip sometimes points people out to me around town who he has seen test positive in clinic but do not take medication because they have what he calls internal stigma. At home, most patients hospitalized because of HIV fall into this category. For one reason or another, social, psychological, economic, they know their diagnosis, but do not treat. Here, however, most of the hospitalize HIV patients are newly diagnosed. One woman came in with an angry series of painful sores on the left side of her face, swelling her eye shut. Such a severe case of herpes zoster is unusual in people with normal immune systems, so an HIV test was ordered for her. She was positive. A 22-year-old man who came in severely wasted, all skin and bones, who laid in bed with glazed over eyes, conscious, but not answering questions. His altered mental status was due to...meningitis? HIV encephalopathy? Without the tools to do a lumbar puncture, we could not definitively diagnose him, so, he was treated for meningitis, in case of concurrent infection. It's too bad, to have to use precious drugs to make diagnoses via empiric treatment, in a place that has a limited supply of everything to begin with.

Obstetrics and anesthesia: The obstetrics that I have seen here has only been surgical, that is, patients who have had a complication that necessitates surgery. The vaginal deliveries are, for the most part, handled by midwives. (In fact, when I went to the OB ward and asked for the doctor, the midwife was offended that I didn't take her qualifications seriously. I had to apologize and explain that I wasn't used to having midwives available.) So unfortunately, the obstetric cases I have seen have been dramatic. The most recent was a woman who came in, complaining that her baby had stopped moving. She was full term, but on exam the baby was high in her belly and close to the skin. On ultrasound, her uterus was empty. Her vitals were stable, so we assumed that she had had the rare diagnosis of an abdominal pregnancy, i.e. a fetus that grew in the abdominal cavity and not in the uterus. In the OT, we were proven wrong: the woman's uterus had actually ruptured, emptying the fetus into her belly. She received a hysterectomy, after the surgeon confirmed that she had 6 children already. It was remarkable that her vitals had been stable for so many long hours. (Emergency surgeries don't happen so “stat” here.)

If the drama of watching the surgeon perform this life-saving surgery was not enough, the anesthesia started wearing off in the middle of the procedure. Mid-surgery, the patient was moaning and moving her hands and feet. Her belly was open and her uterus was being taken out. At one point, she reached forward with her right hand and actually grabbed at the surgeon's gown. He looked down at her hand, mildly surprised, and since the nurse anesthetist was busy tying her other hand down and finding more anesthesia, I slipped in and held her hand out of the sterile field. I stroked it for reassurance at times, and literally arm wrestled with it at others. I had to focus to prevent my own lightheadedness. The poor anesthesia was distressing me. The patient made it through the surgery, and the next day, she thanked the doctor for saving her life. I wonder what she remembered.

Disease here is not all social and infectious disease, and care is not only defined by the paucity of resources. Despite the stories I have chosen to tell, a lot of the medicine here is the same as it is at home. Counseling and kindness are practiced in both places. For example, after rounds last week, our new clinical director, a young Ugandan man named Dr. Kalisa, went to see the mother of a hospitalized, malnourished child to explain what good nutrition entails and how to provide it. Another day, he asked the nurses to wheel a severely depressed patient outside so she could see the sun and perhaps feel some will to live. These small touches, which aren't prescribed by any protocol, are thankfully practiced by good clinicians everywhere.

I truly admire the breadth and depth of knowledge that the African doctors have. The Ugandans I have worked with transition from quiet patient counseling to pediatric ICU care to fast-paced surgery effortlessly, and on top of that, they are have been so good-natured and unflappable. Although some of the doctors at Martha Tubman are Liberian, none have received their training in-country. They have all trained in Uganda and Nigeria, both post-British-colonized countries with good and intact education systems. Similarly, there are no Liberian medical students here, only myself and Clare, a British medical student here with Merlin. Only four to twenty medical students graduate from the University of Liberia each year.

My mind is not playing tricks on me: people do die here more frequently than at home. I have heard about more funerals in the last month than I have in the last ten years of my life. The scrub nurse's mother died, our outpatient clinician Othello had a death in the family, one of our staff members, James, had an uncle pass a few weeks ago. And I have heard the explanation, “She went to Ivory Coast for a funeral,” from the accompaniers who are tracing patients more than several times. In this setting, then, it doesn't surprise me that the routine safety pause spoken by the nurse before surgery is a prayer to God. Sometimes the prayer is made for the patient, and sometimes it is made for the doctor. At home, before the first incision, the nurse pauses only to recite the patient's name, date of birth, and the procedure to be performed.

Thanks for reading. Next time, I hope my missive will be a little lighter. I'll tell you about some of the fiction I've been reading.

Good night and good luck,
Roona