28November 2007

I spent 7 weeks in Kapsowar, Kenya which is in the highlands of the Rift Valley surrounded completely by difficult but amazingly beautiful terrain. This placement was found through

Africa Inland Mission. Then 4 weeks in Kabale, Uganda; a larger town on the route to the famous gorillas and Bwindi Impenetrable Forest. Similarly, it was in the highlands but was independantly arranged directly with the hospital, Rugarama health centre. Some of the following stories are reflections on a challenging and rewarding 3 months away.

A 2 year old girl, presents to the hospital with dehydration, diarrhoea, vomiting and fever. Examination and investigations (that are available) are performed but little explanation is found. She has been off her food for a number of months and developmentally struggling also with no obvious reason. Progressively with hydration and daily meals the acute symptoms resolve but the puzzle is not put together. Until one test gives the answer that no-one wants to hear. This patient had what would be called ISS or Immune Suppression Syndrome, which is a code word for HIV/AIDS.

But this disease was not just hers – she had to have got it from someone. The patient, her mumma (Gloria*) and a nurse sat in front of me in a room with pictures on the wall and toys surrounding us that the child would probably not live to learn to name. Gloria wept as we told them the diagnosis. To her, this disease was a black box which ended in loneliness and death. As she broke down, she shared that her husband had another wife with promiscuous sexual habits. Gloria, her husband and his other wife were tested; all were negative except Gloria. In disbelief I checked the results multiple times, but it was true. She had been living without symptoms for years and may continue to do so for years longer, even forever. But even if she never succumbs to effects of the disease, her struggle will be the permanent label of HIV - Gloria, her youngest daughter and the baby in her womb have a label that may well lead to the loss of husband, family, acceptance and love.

This little girl and mumma caught breath and touched my heart. You can’t travel to Africa and not be touched by HIV. It’s what we’ve read about, it’s the disease everyone in the west is trying to find a cure for, but it’s the disease Africa continues to ignore. Stigma has such power over these people.

Gloria was given an appointment to come back to the ISS clinic with her children, but with attendance for these appointments at only 10%, it is unlikely she return. There is treatment available, at a very low cost, which extends life considerably. But the choice to be tested is much harder than we could ever imagine – It’s the choice between progressively deteriorating and dying (albeit with suspicion surrounding your death) but still having family and friends by your side, or alternative, finding you’re positive and living longer, but living ostracized and alone. Which would you pick?

A 27 year old woman, confused, febrile and drowsy, deteriorated after admission and went into a coma. Her husband visited once a week at most. With little history, no ability to culture organism and little capacity to perform a decent chest X-ray, the outlook seemed pretty bleak. An HIV test came back positive (as do about 40% of the tests in this particular hospital) which led to pages and pages of drug charts… Anti-retrovirals, general antibiotics (gentamycin, ampicillin, metronidazole), pneumocystis carinii pneumonia prophylaxis (co-trimoxazole), cryptococcal meningitis treatment (fluconazole)… Little improvement led to the addition of anti-TB meds to this great regimen. Miraculously, over a period of a week, she became more and more alert, communicating episodically. One confused morning she spoke of her husband’s violence towards her but she could hardly put words together. The nurses chose to put it down to confusion. She continued to improve and gain full function despite being emaciated and weak. When I left, her most pressing medical problem was bed sores that were penetrating to the ischium (which should have had a skin graft by now). Who knows which medication worked but praise God they did! Before her skin graft surgery, there was a push for early discharge as her husband had taken to going to the local pub and returning in the early hours to take advantage of other female patients on the wards. Thankfully, instead he left on a trip to find money he claimed would pay for her admission, which he seemed to drink away. I was given a few opportunities to speak to this woman, whose story sounded so similar to what you’d hear from a woman caught in domestic violence in Australia. “But he buys me nice clothes” and “he’s nice to me when he doesn’t drink”. It was the life she’d been living for 10 years; she could see no other.

The sight of this woman brought such joy and yet such sadness. To think that she’d survived the ordeal, that she’d made it through, her lymphocytes increasing, her strength gaining each day. What could I do but smile! And she would too – each time I walked past she’d ask for yet another photo! In

Reflections on a student elective... I’m a final year medical student who had the

opportunity to do her clinical elective in rural Kenya and Uganda over summer.

29November 2007

situations where you can do so little diagnostically or treatment-wise, you learn to pray for each of your patients, because you feel so helpless to do anything else. And God answers. I’m sure he answers similar prayers here; it’s just easier for us to take the credit!

The nurses’ response to this woman’s claims of abuse shocked me. I was brought up with such differing views. Value, choice, the ability to stop and rest. Each of these things are integral to my life, and yet they are so far from what many African women experience. They not only bear, feed and look after the children; they work in the field, go to the market, retrieve the water. All this in mountainous terrain, sunshine or rain, ankle deep mud (which I’ll kindly inform you, is not pleasant!) or orange dust, day in, day out. More often than not, the men will spend much of the day at the hotel watching people walk up and down the main street.

have us smiling with 96% the following day and was finally allowed to head home.

I was amazed at the quality of care for these premature babies. Yes, many more didn’t make it than would here, but they had procedure and protocol that kept significant numbers of very little babies alive. If the babies were 1kg or over, they had a greater chance of surviving than not which definitely surprised me! God had placed each of the little ones on the medical director’s heart, He had provided the willing hands of the doctors and nurses and had challenged people around the globe to participate and sacrifice. What a privilege to witness God’s plans being carried out by faithful servants.

Three months in another country, another culture, another language, far from everyone I knew was not an easy situation. But that fact did not take one ounce of greatness from the experience – rather it added to it!

Reflections on a student elective... By Myfanwy Geyer Final year medical student,

Adelaide.

...in Kenya & Uganda850g Meshack* would have an 84% chance of living in Adelaide with the support of equipment and specialists at the women’s and children’s hospital. Take him out of that situation and put him into a situation where he: shares an incubator with 2 other premature babies, has nasal pronged oxygen maintained at no more than 3L/hr most of the time(assuming good power), is fed his mother’s milk (hand expressed) through a nasogastric tube, and lives with approximately 10 other babies and their mums in the same room for the next 2 months! Meshack gradually came out of the woods, putting on weight and getting stronger (up to 2.4kg at 2 months), but he would drop his oxygen saturation to the 60%’s when an attempt at weaning was made. He maintained at 98% on 1/8th of a litre but as soon as you switched it off, it would plummet! After continuing like this for a number of weeks, crunch time came. The family could no longer afford the admission (2 months) and threatened to take him out of hospital. Decisions were made to make the rest of the admission free to allow him to continue getting this life giving oxygen. The following day, we walked into the premature room and the nurse was beaming, his saturation was 88% having been off oxygen for 20 minutes. We checked it once more – 92%!! So the waiting game began – 30 mins later 88% and it continued to hover around 90% for the following day. He continued to

How hard it is to rely on God solely when you have people who support and love you just around the corner.

How hard it is to trust fully in him when, if we are truly in need, we can go to the shops and buy the required item, or order every test under the sun to seek a diagnosis.

How hard it is find time to spend in quiet reflection when we are surrounded by (and engulfed in) a culture that is driven by achievement and reward for work.

And how hard it is to remember the lessons once learned and put them into practice!

*Pseudonyms used

29November 2007