Wednesday, December 1st is World AIDS Day — a day to raise awareness for the ongoing AIDS pandemic around the world and to remember the past. As a trainee intern I spent 3 months in Zambia (see ‘A Change in Condition’), a time that really opened my eyes up to what AIDS was doing to the world.  Much has changed since then, antivirals have arrived in Zambia for instance, yet the disaster continues: 1 in 8 Zambians are HIV positive and the burden of AIDS has now persisted for 3 decades.

This is what I wrote about my experience and views on the AIDS crisis in Zambia back in 2002.

The AIDS Crisis and Zambia

Before my time in Zambia, I knew that the AIDS crisis was a serious global problem. However, until my arrival at SFH I never fully realised what that meant. When personally confronted by it, the horror of AIDS defies expression.

In Zambia 1 in 5 adults are HIV positive (1). The life expectancy of a baby born in Zambia today is now thought to average as low as 37 years. Of 15 year olds in Zambia, 60% will die of AIDS (2).  When seeing Zambian children I often find myself wondering which of them number among the country’s plague of orphans (1). It is hard to imagine that children can have AIDS, that they can have a life of sickness ahead of them – a Hobbesian life: “nasty, brutish, and short”.

The italicised paragraphs below are excerpted from a letter published in the British Medical Journal (3). This letter was written by Dr A. W. Logie, who contracted HIV while working at SFH and later died of AIDS. The paragraphs describe the impact and some of the causes of the AIDS epidemic in Zambia and in Africa as a whole:

“… AIDS in Africa is not merely a medical problem: it is having major socioeconomic effects. Industrial output is falling as a result of the premature death of many skilled workers. The traditional extended family care system has broken down. In Zambia, there are almost half a million AIDS orphans, of a total population of 10 million, and many of these are on the streets, easy prey to exploitation, especially sexual abuse.

More teachers are dying every day than are being replaced. Education is suffering, and many children, especially girls, are being withdrawn from school because of unaffordable fees. Poverty or abandonment or both is forcing many women to sell sex in return for food for their families. Lack of respect for female sexual rights, dry sex, poor facilities for the affordable treatment of sexually transmitted disease, unpopularity of the male condom, unavailability of male and female condoms, insufficient research, and development of safe, effective, and acceptable vaginal virucides and vaccines: these and many other factors are contributing to the inexorable progression of the pandemic throughout the Third World.”

The Stigma of HIV

It is hard to know how many patients on the wards at SFH are infected with HIV. On St. Augustine I would estimate three out of every four or five patients.  Before working at SFH I think I must have naively imagined that everyone passing through the hospital doors would have a sticker placed on them stating their status. In my experience, very few people will agree to have an HIV test performed, even after special counselling. A study found that “only 7% of couples invited for counselling and testing in Lusaka decided to have a test”(4). One of the reasons must be that there is very little to gain from having the test done. In Lusaka the most common reason cited for declining a test was that “no medical intervention was available”(4) – it seems that as long as a person’s status is uncertain there is still hope. Of those infected with HIV in sub-Saharan Africa, 90% are thought to be unaware of their infection (4).

All that can be gained by an HIV test is stigmatisation. At SFH, if a patient is to be counselled about having an HIV test the identity of their bed-side attendants is always checked first. If the patient is a man and HIV is mentioned while his mother is present, the man’s wife may be held to blame. It seems that the mention of HIV has the capacity to wreck someone’s life, just as the virus itself can cripple a whole nation.

Abuse of Authority

Stories of the abuse of authority abound in Africa. A commonly cited form of abuse is a male authority figure extracting sexual favours from females. Male secondary school teachers are often a threat to female students for this reason. A graphic example of this is the suspicion that a male teacher is responsible for HIV prevalence rates of 30% at a school in one of Katete’s neighbouring districts. The average prevalence rate in secondary schools is thought to be less than 5%. Africa seems to be overflowing with horror stories like this.

Infertility and Polygamy

Another aspect of sexually transmitted disease I had never fully appreciated before is the importance of infertility associated with pelvic inflammatory disease. At an infertility clinic I was stunned to see the vast numbers of women unable to get pregnant. The consequences of this are extreme. It seems that infertile women are considered next to useless, and their husbands often resort to polygamy (5). Ironically, almost all the semen analysis results that I saw at the infertility clinic seemed to contain pus cells, suggestive of infection. Thus, it is often the husband’s sexual indiscretions that have actually led to the infection of his wife and her subsequent infertility.

AIDS Education

I was overwhelmed by the prevalence of sexually transmitted infections when I started working at SFH. However, measures to fight the pandemic are in operation. SFH has an AIDS outreach programme that sends a group of trained health worker-come-actors on  tours of the local villages. They perform plays and encourage discussion to educate people about AIDS. Billboards carrying anti-AIDS information line Zambia’s streets, and men roam Lusaka dishing out handouts on “genital leakage”. However, there appears to have been little real impact in terms of changing sexual behaviours (2) despite apparently widespread public awareness and health education. For instance, I found that many male patients seem to agree that the use of condoms is a good idea. However, their view is usually that it’s a good idea for someone else – in other words, “the someone else who is HIV positive… not me”.

Denial and Hope

AIDS in Zambia has been called “the silent killer – because people are too afraid to admit they have the disease” . On the wards the letters “H-I-V” are spoken only in hushed tones, if at all. Generally, euphemisms like “immune suppression” or “the virus” are used. It took me a while before I clicked onto to what “?RVD”  written at the bottom of an admission note meant – “possible retroviral disease”. I’ve considered trying to establish my own euphemism in readiness for when the others take on unwanted connotations. Perhaps “an RNA-based life-form associated illness” would do, it could have a nice acronym like “ARNALAI”.

Seriously though, such denial can only be damaging. In 1999 the Zambian government initially denied the UN estimates of 20% adult HIV prevalence rates (1). Furthermore, as stated by Dr A W Logie, “The Zambian government has largely abandoned responsibility for HIV/AIDS and tuberculosis to the non-governmental organisations. Now local supervision programmes for tuberculosis treatment do exist, but they are mainly organised by non-governmental organisations” (3). Also damaging in recent times has been the opposition of the Catholic church in Zambia to the use of condoms (6). Health workers need to face up as well, it has been reported that “HIV is rarely entered in African death certificates, yet treatment decisions are made on the assumption that a patient is infected” (4).

Progress in the fight against AIDS will only be made when those on the battlefield face up to the disease. This can only happen when the stigma is taken away and local leaders rather than “meddling mzungus” lead the way. Benefits such as access to medical care and tuberculosis prophylactics need to be offered to HIV positive people to promote testing. The denial and stigma of HIV must be eroded away. I think there is some hope – not much, I admit, but perhaps enough.

Footnotes

(1) Moszynski  P. United Nations estimates of HIV prevalence in Zambia under attack. BMJ 1999;319:338.
2) Logie D. AIDS cuts life expectancy in sub-Saharan Africa by a quarter. BMJ 1999;319:806.
(3) Logie A W. Africa revisited: a distressing experience. BMJ 2001;322:59.
(4) Godfrey-Faussett P, Baggaley R. Exceptionalism in HIV – challenge for Africa too. BMJ 1998;316:1826.
(5) I will always remember the time I asked the identity of the two women at a male patient’s bedside and the nurse matter-of-factly responded, “they are his wives – he is a polygamist”.
(6) Jackson T. No news is bad news. BMJ 2000;321:14194.

Another St. Francis’ Hospital/ AIDS related BMJ article was written by a former physician at the hospital: Elphick D. Memorable patients – Zambia needs basic medicines and HIV education. BMJ 2002;324:895.

Other related LITFL posts based on my experience in Zambia include:

• A Change in Condition
• The Shrinking Feet of the Man from Malawi
• A Midsummer Night’s Dream
• World AIDS Day and the Crisis in Zambia

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Mr J had traveled across the border to Zambia from Malawi. He had been admitted to hospital overnight. The brief admission note showed that he was in his thirties and had three presenting complaints:

(1) “hungry”

(2) “shrinking feet” and

(3) “does not want to answer anymore questions”.

A blood slide showed the presence of malarial parasites, and anti-malarial treatment was started. His feet were measured in an attempt to show objectively that they were of a size typical for a man of his age and stature and that there was no ongoing decrement with time. By the time the doctors saw him the next day he was handcuffed to a bed – he had apparently been “scaring the nurses” during the night. A “psychiatric” referral was arranged.

Notes on the shrinking feet of the man from Malawi (1) (photo by Paul Young)

Notes on the shrinking feet of the man from Malawi (2) (Photo by Paul Young)

The psychiatric assessment was summarised by a list of three “impressions” at the bottom of the page:

(1) “psychopath – aggressive type”

(2) “Ganser syndrome”, and

(3) “Criminal”.

“Ganser syndrome –what the @#$% is that?”, I hear you cry in despair. The Oxford Handbook of Clinical Specialties has the following entry under ‘Some unusual eponymous syndromes’:

“Disorientation plus pseudodementia with ‘approximate answering’, e.g. an answer to ‘What is the colour of the chair in the corner?’ might be: ‘What corner? I don’t know what a corner is. I don’t see a chair…’ … Often there is a preceding head injury.”…

He was then administered what seemed the universal treatment for psychiatric illness in Zambia at the time, big doses of chlorpromazine.

The next day he again had three complaints, this time they were:

(1) “dry mouth”,

(2) “sleepiness”, and

(3) “too many drugs, and not enough food”.

It became apparent that Mr J’s main problem was hunger, a consequence of poor crop yields in Malawi that year. As for the diagnosis of malaria, in endemic regions even completely well individuals may have a malarial parasitemia if tested. Mr J’s complaint of ‘shrinking feet’ appeared to be an imaginative strategy for obtaining food by getting admitted to hospital. However his strategy back-fired as it led him into the strange world of an Africa-style ‘One Flew Over The Cuckoo’s Nest’.

Ultimately, Mr J agreed to continue taking his medicines when he was told he would be fed and discharged in a few days. Soon after his discharge he returned begging for money to allow him to travel back to Malawi. A nurse told him that he might be able to hitch a ride on an ambulance returning to a town near the border and he was sent on his way.

Other related LITFL posts based on my experience in Zambia include:

• A Change in Condition
• The Shrinking Feet of the Man from Malawi
• A Midsummer Night’s Dream
• World AIDS Day and the Crisis in Zambia

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

2002 was the year I became a doctor. It is easy to forget the growing pains of the student-to-doctor metamorphosis. For me, the once vague notion of becoming a doctor was made real when I traveled to Zambia to work on the wards of St. Francis Hospital (SFH) in Katete:

Inevitably, every medical officer working at SFH encounters a tap on the shoulder from a nurse followed by the quiet echo of the whispered words, “Doctor, there has been a change in condition”.

Usually, this means a patient has died. Sometimes the patient is still in the last throes of trying to die. Invariably, there is very little that can be done. The patient may have been dead for sometime and an over-worked nurse has only just noticed his or her lack of responsiveness. Or you may find that the suction is not working or the mask and bag has gone missing, thus robbing the dying patient of a last breath. Woven together such experiences form the grim reality of life and death in a “developing” world hospital.

The phrase ‘a change in condition‘ also aptly described how my experiences in Zambia affected me. Many times I felt a chill and imagined myself a naïve Charlie Marlow journeying to the ‘Heart of Darkness’. At times the dying words of the maniacal Kurtz  resonated in my thoughts – “he cried out twice, a cry that was no more than a breath – The horror! The horror!”. I too underwent a change in condition.

I remember my first ward round on a Sunday morning, two days after arriving in Lusaka. I was still jet-lagged but in a state of agitation fueled by curiosity and enthusiasm. The ward round covered all the surgical and obstetrical/ gynaecological patients in the hospital. This equated to approximately seventy or eighty patients (I couldn’t keep up with the fast pace of the count), and lasted barely two-and-a-half hours. My eyes could hardly adjust to the darkness of the wards, and when they did, they were barely prepared for what they saw. I was struggling to keep my head above water in an ocean of dripping pus, sunken eyes, and protruding ribs.

Soon after I arrived at SFH I paid a visit to the SCBU – the special care baby unit. The room was filled with stifling heat and the walls were lined with boxes with large windows. Through each window one could see a skeletal newborn staring back with eyes wide. A disturbing image of a department store filled with microwave ovens entered my mind; each containing assorted leftovers waiting to be re-heated. Actually I was fortunate – my arrival had followed the eradication of most of the cockroaches that once infested the SCBU. It was said, if one looked closely, that nibbled bite marks left by the cockroaches could still be seen on the tiny toes of the undernourished newborns.

Images are one thing, smells are another. My first walk through the SFH wards took me back to my childhood. As a youngster I used to hand-rear birds and kept an aviary. The background scent of the hospital had the same agricultural odour. As I circulated the hospital, many other scents – none  pleasant – also came to the fore. These smells were representative of all the bodily functions of which human beings are capable, plus all the products of the fermentation of countless micro-organisms. Sometimes the odours were so strong I had to consider carefully whether a gasp of air was less harmful than death by asphyxiation.

My introduction to working on the male medical ward included admitting and treating a prisoner from the local jail. The man was in his early thirties. He was debilitated by a chest infection and chronic diarrhoea, which compounded his severe malnutrition and suppressed immune system. He had the appearance of a skeleton lightly clothed, in part, with a thin layer of dark skin. Pus gushed out of a wound an inch long upon lifting his right forearm, and the crackle of bacterial gas beneath the skin was palpable. The prisoner had sustained the injury by defending himself with a raised arm against the swing of a farmer’s hoe. The wound then shared the usual fate of a breach in the skin’s defence in Africa – infection. I helped the patient to lean forward, thus allowing his back to be examined. I was hit instantly by the surge of an insipid wave of ammonia that rose from his urine-soaked clothes. Across his back stretched a thick line of bleeding flesh, perhaps the only clean wound on his body (and probably an indication of the antiseptic quality of urine). His left ankle was a gaping purulent crater. Chronic osteomyelitis had eaten away at both his bony and soft tissues. Elsewhere, his body bore the numberless punctured impressions of human jaws. As time passed his leg wound teemed with hungry maggots that ate at the dead flesh, baring the ruptured tendons and decaying bones of his left foot. The surgeons eventually took over the man’s care. Last I heard, the poor man was accused of keeping himself sick to avoid a return to prison. Who could blame him?

…“The horror! The horror!”…

After my first day at SFH, I wondered how long it would be before I became desensitised to the enormity of my surroundings. Only a week later, it seemed almost normal to see a room of thirty  young men, cachexic, with sunken eyes, and mouths filled with the white curd of candidiasis.

Initially, I felt that medicine in Zambia was a hopeless enterprise. However, I soon learnt to value the things that could be done. Treating candidiasis to allow a man to swallow with some comfort, or giving analgesia to relieve the bone pain of multiple myeloma are brief examples. While there seemed to be a strong palliative component to medicine on the wards, many conditions were curable. There are few occasions in life as rewarding as helping a fitting child to fight off cerebral malaria, bringing a young man back to consciousness with the treatment of life-threatening bacterial meningitis, or hearing a man offer his thanks after the spasms of tetanus have subsided.

At SFH I experienced the fullest range of human emotion. I experienced the greatest challenges of my short medical life. I had my eyes opened to a world I had never before seen. The time I spent at SFH was beyond value and will continue serve me well for the rest of my personal and professional life.

(Originally written in 2002)

I went to Africa a student and came back a doctor.

St. Francis Hospital, Zambia

St. Augustine Medical Ward, St. Francis Hospital (Photo by Paul Young)

For those interested in working at St. Francis Hospital in Zambia or planning an elective there I recommend the excellent up-to-date ‘rough guide’  written by Adam Archibald.

Also of interest on ‘Life in the Fast Lane’:

• A Midsummer Night’s Dream

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Nick Bottom: “I’ll speak in a monstrous little voice.”
- from Act 1, Scene ii of A Midsummer Night’s Dream by William Shakespeare (~1596).

One day, as a trainee doctor working in rural Zambia, I walked through the gates of the hospital to be greeted by what seemed to be the “eeyore-ing” of a demonic donkey. My eyes and ears scanned the courtyard and corridors but could not locate the source of this bizarre noise. After a brief pause I resumed my brisk walk to the male medical ward. As the ward round started, the source of the noise arrived and found me.

Mr D was a young-and-healthy-looking man in his twenties. His presenting complaint was intractable ‘hiccups’ that had tormented him (and everyone else within earshot) for over two months. The hiccups were violently loud, rapidly repetitive, and associated with a great deal of belching and tic-like facial movements. Interestingly, the hiccups subsided whenever Mr D had food in his mouth and when he slept at night. An obsessive clinical examination yielded no other findings of note. A psychogenic cause was suspected.

I learned from Mr D that he had been cursed by a local village woman. I also learned that the purpose of the curse was to prevent him from working on his father’s farm, and to ruin his marriage prospects. It was clearly working. With the help of the nurses I tried to reassure Mr D that there was nothing physically wrong with him and that the curse would only be effective as long as he believed in it’s power over him. Unfortunately, his conviction in the power of the curse was strong, and thus the curse was powerful. Mr D did concede, however, that the curse would wear off eventually. For his (and everyone else’s) benefit we tried to convince him that that time would come sooner rather than later. Mr D even agreed to a trial of chlorpromazine to control the hiccups, but the drug simply didn’t work.

In the end we resorted to encouraging our patient to keep working despite the hiccups and even to try walking around with food in his mouth. He was discharged soon after, donkey-like hiccups and all. I was left to reflect on my therapeutic impotence in silence. I still wonder what happened to Mr D.

“Faith in the gods or the saints cures one, faith in little pills another, hypnotic suggestion a third, faith in a plain common doctor a fourth.”
- William Osler

Puck: “Lord, what fools these mortals be!”
- from Act 3, Scene ii of A Midsummer Night’s Dream by William Shakespeare (~1596).

A not-so-demonic donkey

Other related LITFL posts based on my experience in Zambia include:

• A Change in Condition
• The Shrinking Feet of the Man from Malawi
• A Midsummer Night’s Dream
• World AIDS Day and the Crisis in Zambia

Life in the Fast Lane Medical Blog - Emergency Medicine education blog