Saturday, October 18, 2008

A really sh-tty week

I’ve had another difficult week here in Swaziland. I have cried everyday. It is becoming increasingly difficult to get out of bed each day. I can’t tell if I’m depressed or whether this is a perfectly normal response to what I am seeing here.

My week started badly in that I was inundated with new admissions. I had 12 new admissions to start my week and this is on top of the 20 or so other patients I already had on the ward. The next day, I had a further 10. It’s not like I have another resident to run around and assist me (like at home). I run the whole show and I do everything from all the paper work, all the procedures and all the decision making.
Not only do I see all the medical patients, I am also asked to consult on the gynaecology patients and the surgical patients. They all have HIV and this is considered a “medical” problem, so I am often involved in their care as well. I find it all thoroughly overwhelming. I am exhausted.

The patients are not simple. In fact that are often far more complicated than what I deal with at home. The problem that I face on an everyday basis is that my patients often present to me in an advanced stage of their illness. People are not getting tested for HIV and they often present to hospital with their AIDS defining illness. For those of you who do not understand the difference between HIV and AIDS, I will give you a very brief and simple explanation.

HIV is the virus that causes AIDS. It infects cells of the immune system called CD4 cells. It destroys these cells so that immunity is lowered and the body is then susceptible to catching really serious infections and malignancies. You can assess the progression of the illness by obtaining a CD4 count. Anything less than 200 is considered AIDS because the immune system is so depressed that it is vulnerable to infections that we, with intact immune systems, can usually deal with. We try to start people on Anti-Retroviral (ARVs) Drugs when their CD4 count is 200 or less.

The trouble I face here in Swaziland is that people are presenting to my ward with CD4 counts of around 50, 10 or even 5 (I have had a patient with a CD4 of 3). They basically have no immunity. They present with the most devastating infections such as meningitis (bacterial, fungal, tuberculous), brain infections, pneumonia, diarrhoea, tumours and what is called “wasting syndrome”. If any of you remember the pictures we saw in the 1980s of people who were afflicted by the famine in Ethiopia, then this describes the wasting syndrome perfectly. They don’t just have one illness, they tend to be multiply infected. For instance, I have one patient with a CD4 count of 10. She has what is called HIV encephalopathy which is somewhat like dementia, somewhat like psychosis. She also has PCP pneumonia. She also has pelvic inflammatory disease as well as these horrendous genital ulcers. She also has a raging bacterial conjunctivitis. I have another patient who has PCP pneumonia as well as cryptococcal meningitis. Many of my patients have TB- but not just the pulmonary type- they have TB of the abdomen, pleura, pericardium, lymph nodes and even the skin. We are starting to get Multi-Drug Resistant TB which I see as the next impending disaster here in Swaziland.

I have had a patient on my ward here for sometime and I have been fighting on a daily basis to keep her alive. She was 18 and had advanced HIV with a CD4 count of 35 when she first arrived. She also had lymphoma of the tongue- her tongue was huge and it was difficult for her to swallow. I also think she had lymphoma in her gut because she vomited constantly. We do not have any injectable anti-vomiting drugs here, so I was using antihistamines (which can sometimes help with nausea) and a drug called dexamethasone. I tried everything I could to stop that girl vomiting. Everyday, I would see her and see would be lying in her own pool of vomit. She was so incredibly weak and emaciated that she did not have the energy to roll over and vomit. The nurses were changing her linen constantly, but as soon as she was settled in new sheets, she would vomit again. She was in pain, but the only narcotic analgesia I could give her was oral morphine which she would vomit up. She was so wasted that I could feel through to her spine if I palpated her abdomen hard enough. It destroyed me each day to see her just wasting away. She loved orange juice, so I would go and buy her the juice. She would sip it through a straw because her tongue was so huge with tumour that swallowing any other way was next to impossible. She would then vomit it up, but I knew that she just loved the small time that she had the liquid in her mouth.
This patient died alone on Thursday. Her family never came to see her. She was thrown out when her family found out she had HIV. This happens to many of my women here and it is devastating to me. Despite the fact that the official figures state that 43% of the population here has HIV, it is still an incredibly stigmatised disease. I feel that women here tend to be more affected by the stigmatisation than the men. It is easier for a woman to catch HIV compared to a man. Men here can have multiple wives and multiple partners at the same time and this is considered culturally normal. I feel it is one of the reasons that HIV is so rampant here. Women don’t have many options when they are abandoned by their families or their partners. One of the things which poses a particularly big problem for me and my patients is that in order to be on ARVs, you need to have a treatment supporter who will encourage you to take your medicines. My women are too frightened to reveal their HIV status because they fear abandonment, so getting them on ARV treatment is almost impossible. I have been fighting with my colleagues about this issue, but they are just trying to maintain “national guidelines”. I really feel it is ideal to have a treatment supporter, but what happens to my women when there is no one left around them?

Everyday, I feel that more and more of my soul is being destroyed. I feel overwhelming hopelessness. My sadness consumes me at times. I can’t sleep properly, I look dreadful. My eyes have lost their brightness. I feel so upset by what I am witnessing, that my heart physically hurts at times. At times I am angry and bitter. I don’t like feeling this way. This is not who I am, but I fear it is what I am becoming. I fear that my friends won’t like me when I get home, because the very essence of who I was seems to have disappeared. And yet, I keep going, because everyday I think of my patients. Despite the devastation that surrounds me, I am inspired to keep fighting for them. They are the only reason I am able to find the energy to get out of bed.

On Wednesday, at the height of my despair, I decided to walk into town. I have restarted to walk into town because I need the exercise and it helps improve my mood and clear my thoughts. Instead of the Swiss army knife, I now carry a large umbrella as my “weapon of choice”. It is bright pink and it is called “Mary Poppins”. When purchasing this item, I felt like I was being given a sign. Mary Poppins would never let me down. If needed (and I certainly hope I never have to), I could wield it like a baseball bat.
Anyway, I started off into town. My stomach started to make some rumbling sounds and spasms were starting to make me feel uncomfortable. I kept going thinking that this was just my emotions getting a hold of me. About midway into town I was hit with the sudden realisation that I was about to have my first episode of diarrhoea here in Swaziland. I felt absolute panic. Certainly no public toilets on the way to Siteki. I started to think that I may have to go on the side of the road, but I had two prevailing thoughts:
Firstly- Snakes. What if I was to squat and then have my butt bitten by a mumba?
Secondly- I am the most recognisable person here in Siteki. My white skin, dark long hair
and the fact that I work at Good Shepherd makes me recognisable by most people. I don’t speak SiSwati, but I do recognise that I am a “dokatella” and I can hear people talk about me when I walk past. I simply could not be seen squatting on the side of the road.
I started running back to Good Shepherd. I felt that if I could get my “fright and flight” response going, then perhaps I could try and distract my bowels from relieving themselves. My lungs were burning from the intensity of my pace. My butt cheeks were burning from trying to avoid incontinence. I started cursing myself for wearing my $50 pale pink lace French knickers, because I felt that they may soon be destroyed. I cursed myself for not washing the spinach thoroughly the night before, because this may be the cause of my impending doom.
I eventually reach my flat and I can only describe the experience as an atomic bomb going off in my large intestine. It was horrendous. I then went to flush the toilet and I find that the toilet can’t cope with the volume. My heart stopped beating as I saw the toilet water and its contents rise to the top of the bowl. I was filled with horror and then, by some miracle, it all disappeared before spilling over the edge. I fell to the ground in a heap of relief and exhaustion.
I now have to re-write my list of things most feared on my walk into Siteki:
1. Swazi men
2. Goats and Cattle
3. Snakes
4. A repeat episode of explosive diarrhoea.