Since coming to Malawi many people have asked me some version of the same question: Is it what you thought it would be? Well, thanks to the breakneck pace of medical school I had very little time to consider what I might be getting myself into, and even less time to develop preconceived notions of how I might find Malawi or my project. That being said, I have been surprised, almost daily, by my experiences in Malawi. To alter the tone from my last post, most of the surprises I discuss here have been pleasant and/or interesting surprises and have in some cases bolstered my resolve to continue my work and to continue seeking out new experiences.
In considering two children who are treated in a Malawian hospital, both for pneumonia, one could reasonably guess that if one child was HIV-positive and one was HIV-negative the child without HIV would have the better prognosis. In actuality I can say very little about the prognosis of children admitted to KCH with pneumonia. However, what I have been surprised to find is that of these two hypothetical children, the HIV-positive child is likely to get a much higher quality of care. Moreover, in a hospital like KCH, where children die not just because of their pneumonia (or any other chief complaint), but are daily threatened by medical error, poor hygiene, understaffing and limited resources, the quality and regularity of care are essential variables in determining prognosis.
The reason for this disparity of care is that all HIV-positive children at KCH are referred to the Baylor Pediatric HIV program. This program provides treatment and care to over 2,000 exposed or infected children. If an HIV-positive child (or a breastfeeding child born to an HIV-positive mother) is admitted for care at KCH, Baylor clinicians will round on the child daily and follow up to ensure the child receives proper care. In contrast, children who do not have this high quality of care often die because they are given the wrong treatment, miss life-saving treatments such as oxygen or blood transfusions, or for other reasons not directly related to their diagnosis. Sadly, these misfortunes befall children enrolled in the Baylor program as well, but (I sense) at a much lower rate. While I do not have any scientific data on these care discrepancies, from what I have seen, they can truly make the difference between life and death.
A second surprise (and to be honest, the one that has been personally most surprising) is how much I like pediatrics. Those of you who know me know that since starting medical school I have never considered becoming a pediatrician and have had little interest in treating kids. Yet, I have found that I really like working with the kids here. Perhaps part of it is that the parents we deal with are not the pushy, hyperattentive parents I fear having to work with in the States. Or because the kids I see are so sick that kicking, crying, and being uncooperative are, in this context, welcome signs of life rather than annoyances.
Beyond gaining an appreciation for the patient population in pediatrics, I have found myself fascinated by the field because, as I see it, pediatrics is essentially public health in action. My layman’s understanding of public health is that its primary goal is to keep populations healthy by a.) dealing with groups of people rather than individuals and b.) preventing health problems before they start. In doing so, public health deals with social justice, environmental issues, economic fairness and a host of other societal issues that are important to me.
I have found in pediatrics that in order to treat the child you often have to treat the entire family. This means not only ensuring the health of the mother and siblings (which is also essential) but also working to establish within the family a degree of social justice, a healthy environment and a sustainable economic structure in order to heal your patient. Moreover, by addressing childhood health issues you are by definition practicing preventive medicine; facilitating your patient’s growth into a healthy adult.
Examples from the past weeks abound. One little girl, a 14 year old who physically appeared to be about 8 years old, presented to an outpatient clinic months ago. She was very sick and HIV positive. A Baylor pediatrician treated her and sought out her family in order to test her parents and siblings for HIV. Surprisingly, the other members of the family were all found to be HIV negative. After building trust with the patient and her mother, the physician found out that the little girl had been sent away from the family to work as a maid. She was living with sex workers and had no adult care or supervision. Likely, the patient contract HIV through sexual assault or by becoming a sex worker herself.
Thus the pediatrician took on the work of healing the whole family in order to ensure that the treatment she gave her patient would actually work. This involved planning, with the patient’s mother, a financially feasible way to bring the patient back home. Once the child was back at home, she then taught the parents how to care for their daughter, and encouraged the mother to consider family planning so as to not conceive more children they would have to send away to work. The most recent mission was to instill in this family the value of sending the patient to school.
While this story had a very sad beginning, and admittedly has the possibility of a tragic ending, the entire family has become healthier in this process Moreover, the 14 year old girl I saw, months after her initial diagnosis, had a high CD4 count, a bright smile, and a chance to start school in the upcoming year. Without the pediatrician treating the family holistically, none of this would have been possible.
Showing posts with label HIV testing. Show all posts
Showing posts with label HIV testing. Show all posts
Monday, June 21, 2010
Tuesday, June 8, 2010
Familiar Job, Novel Setting
Going into today I felt simultaneously that I had a fair amount of experience to bank on, and that I was totally unprepared for spending a day with HIV counselors who would test and counsel mothers and their young children. As a SHAC HIV counselor I have never tested or counseled children or their parents, and I have been lucky enough to have never had a positive. Going into today I knew the former was a definite and suspected the latter would occur before the day was out.
I started my day in the inpatient wards. The team of counselors, Gift, Effie, Lonely, and Gertrude who I worked with (more explanation of Malawian names later) are charged with testing pediatric inpatients who are referred by clinicians, whose mother’s have been identified as HIV+ at intake, or who meet certain clinical criteria. Before the day started Gift introduced me to the other counselors and then helped me practice some of my Chichewa. I learned (and then promptly forgot) how to say “I am going home.” I’m not sure what it means that this was the phrase I was taught at the beginning of the day, but things preceded better than they might have given that start.
In testing children for HIV there are several unique considerations: the first is determining the mother’s HIV status. Of the fifteen (or so) women who we counseled this morning, about three were known to be HIV positive. For these mothers there is a risk (I believe around 10-15%) that they transmitted the virus to their child during delivery, and a continued risk of transmitting the virus through breastfeeding. Interestingly, while there is an increased risk of transmitting HIV during breastfeeding, even over delivery itself, breastfeeding is still recommended for the first year of life.
The reason for this recommendation is that malnutrition in the first six months is a much greater threat to children than HIV transmitted from mother to child, especially if the mother is on antiretroviral therapy. Previous guidelines said to wean children from breast feeding at six months, yet it was found that children weaned at this interval had a high death rate due to malnutrition, and yet still had a high risk of mother-to-child transmission (MTCT) because the solid foods were causing micro tears in the infant’s stomach that, when breast milk was given, allowed the virus to enter their circulation. The recommendation has thus been amended to delay weaning to one year which has been shown to reduce risk of both malnourishment and MTCT. This example is illustrative of the complexities of practicing medicine in such a limited-resource setting. The best intentions can be completely confounded by the overwhelming disease burden of the population.
In addition to learning the ins and out of pediatric testing and counseling, it was interesting to see some of the organizational differences between SHAC HIV testing and testing at KCH. KCH employs a group pre-test counseling session with individual post-test counseling sessions. This allows counselors to test a higher volume of patients, and may have the added benefit of normalizing testing without revealing too much personal information, though as other counselors, hospital personnel and other patients often barged in on pre- and post-test counseling confidentiality was certain lacking in both the inpatient and outpatient wards.
I asked one of the counselors whether people had upset reactions to positive test. She told me no, people just accept it. When I’m counseling a patient in Durham who tells me about high risk behaviors, and I being to suspect they are infected I feel a panic start to rise. Of course, it is my job as a counselor to push the panic down and help the patient deal with the test results. Yet, I found that when HIV+ mothers came in with their newly delivered infants that panic didn’t rise. It was as if I too had somehow come to just accept it. I’m not sure what this means. We didn’t deliver a single positive result today; I suspect doing so would have provoked a much more emotional response on my behalf. But I am still left wondering what it means about me that I didn’t have ‘the panic.’ Am I becoming hardened? Or did I simply adapt?
I started my day in the inpatient wards. The team of counselors, Gift, Effie, Lonely, and Gertrude who I worked with (more explanation of Malawian names later) are charged with testing pediatric inpatients who are referred by clinicians, whose mother’s have been identified as HIV+ at intake, or who meet certain clinical criteria. Before the day started Gift introduced me to the other counselors and then helped me practice some of my Chichewa. I learned (and then promptly forgot) how to say “I am going home.” I’m not sure what it means that this was the phrase I was taught at the beginning of the day, but things preceded better than they might have given that start.
In testing children for HIV there are several unique considerations: the first is determining the mother’s HIV status. Of the fifteen (or so) women who we counseled this morning, about three were known to be HIV positive. For these mothers there is a risk (I believe around 10-15%) that they transmitted the virus to their child during delivery, and a continued risk of transmitting the virus through breastfeeding. Interestingly, while there is an increased risk of transmitting HIV during breastfeeding, even over delivery itself, breastfeeding is still recommended for the first year of life.
The reason for this recommendation is that malnutrition in the first six months is a much greater threat to children than HIV transmitted from mother to child, especially if the mother is on antiretroviral therapy. Previous guidelines said to wean children from breast feeding at six months, yet it was found that children weaned at this interval had a high death rate due to malnutrition, and yet still had a high risk of mother-to-child transmission (MTCT) because the solid foods were causing micro tears in the infant’s stomach that, when breast milk was given, allowed the virus to enter their circulation. The recommendation has thus been amended to delay weaning to one year which has been shown to reduce risk of both malnourishment and MTCT. This example is illustrative of the complexities of practicing medicine in such a limited-resource setting. The best intentions can be completely confounded by the overwhelming disease burden of the population.
In addition to learning the ins and out of pediatric testing and counseling, it was interesting to see some of the organizational differences between SHAC HIV testing and testing at KCH. KCH employs a group pre-test counseling session with individual post-test counseling sessions. This allows counselors to test a higher volume of patients, and may have the added benefit of normalizing testing without revealing too much personal information, though as other counselors, hospital personnel and other patients often barged in on pre- and post-test counseling confidentiality was certain lacking in both the inpatient and outpatient wards.
I asked one of the counselors whether people had upset reactions to positive test. She told me no, people just accept it. When I’m counseling a patient in Durham who tells me about high risk behaviors, and I being to suspect they are infected I feel a panic start to rise. Of course, it is my job as a counselor to push the panic down and help the patient deal with the test results. Yet, I found that when HIV+ mothers came in with their newly delivered infants that panic didn’t rise. It was as if I too had somehow come to just accept it. I’m not sure what this means. We didn’t deliver a single positive result today; I suspect doing so would have provoked a much more emotional response on my behalf. But I am still left wondering what it means about me that I didn’t have ‘the panic.’ Am I becoming hardened? Or did I simply adapt?
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