Impressions Part 2: Surprises

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.