Saturday, September 15, 2007


9/14/07: A clinic

Pamela and I visited one of the HIV day clinics today. It’s a smallish building with small rooms lining an open area with benches where patients wait. Outside lining the wall is a covered area with more benches where overflow patients can wait. We observed the counseling room first. A tecnico medicino gathered about 8 patients in a tiny room with their files and green cards that describe their HIV treatment course. About half looked healthy and half were gaunt with temporal wasting. One man was so thin, he had only sticks for arms and legs. His eyes looked huge in his skull. A nurse had to help him out of the room when he left. The tecnico medicino sat behind a desk (inexplicably adorned with a small stuffed Bambi) and told us about what he does, while the patients looked on stoically. We weren’t introduced to them and we felt a little awkward about that. He explained that these were patients recently diagnosed with HIV at the local hospital or other center and were sent to enroll in treatment. He told the patients that they would need to have a CD4 count checked every 6 months and they would need to take medicine twice a day for the rest of their lives. He told them how to protect their families and to take care of themselves by eating lots of fruit and vegetables, not working to exhaustion, and not becoming stressed. His lecture had the cadence of a sermon or the telling of a fable. He started slowly and then became more and expressive with gestures, his voice got louder and he sounded very stern at some points, especially when emphasizing that the medicine was extremely expensive. He told the patients that they were getting it for free, that many people were waiting for medicine, and that they wouldn’t continue treatment if they weren’t serious about it. The patients watched intently. Then he started to wrap it up with more smiles and phrases like "Nao e?" (Isn’t it so?), that invited their agreement and participation. It had the feel of a performance of some kind. It was interesting to watch, though very different from the counseling style recommended in the States. He then addressed patients individually, hearing a bit of their history and then filling out the needed lab requisitions, sending them to the doctors’ rooms across the clinic, or telling them when to return for their next appointment. One woman, who looked to be in her late teens and her second trimester of pregnancy, told us that when she told her husband she had HIV, he abandoned her and their children. She may have gotten it from him. She had moved back in with her mother and they were trying to raise the children and make enough money to live. Another man in the second round of patients to be counseled, had a cough for a year that wouldn’t go away. He was tested for TB repeatedly, always with a negative result (Note: the test he had was likely a sputum smear, which can fail to discover the TB bacilli especially if done improperly. Additionally, because of a host of immune system changes, HIV + patients have a higher rate of "sputum smear negative TB" and "extra-pulmonary TB"or TB that has spread to other sites in the body. ) He was treated for TB anyway and developed "yellow eyes, yellow palms, and strange colored urine" (Possibly liver damage from the TB drugs. This can be exacerbated by alcohol). The cough was still present when he was finally tested for HIV and found to be positive. He was thirty years old and very, very thin.

A digression on the combination of TB and HIV.......

Mozambique is among the top ten nations for people living with HIV/AIDS. The prevalence of HIV varies from province to province. Nationally, it’s about 12% and is as high as 25% (1 in 4 people!) in some places. Mozambique is among the top twenty nations for TB cases and the prevalence is growing. Forty-seven percent of those with TB are HIV+. Each disease complicates the treatment of the other. TB can hasten HIV progression. HIV+ patients are more likely to have extra-pulmonary TB or sputum smear negative TB. TB is the most common opportunistic infection in sub-Saharan Africa and the most frequent cause of death among HIV+ persons. It is a very big problem and many international health organizations are extremely concerned. Many cases of active TB in countries with few resources to treat it sets the stage for increases in TB transmission and the development of drug resistance. There is a large push toward better integration of TB and HIV care. Currently, in some places there are both TB and HIV clinics, but no communication between them. No one walks a TB patient across to the HIV clinic to get tested for HIV. There is also complex pharmacological interplay between anti-retroviral drugs and antibiotics used to treat TB that could use supervision.

Back to the clinic...

We took a break and ate sandwiches out of our pockets in the backyard of the clinic. There is a covered building with a cement floor in the back that is used for monthly support group meetings where patients are given a meal and encouraged to talk to other HIV + patients. Staff put on skits and musical performances around the theme of living with HIV. There are beautiful abstract murals painted on the wall of Africans taking pills with the red ribbon interwoven. Painted on the concrete floor is the phrase, "We hope for treatment for all."

Back inside, we looked at the lab. It is a small room with capability to do basic chemistry, CBC, and CD4 counts. The equipment was all new and in good shape. We met the two techs working on the day’s batch of labs. The small clinics in Quelimane lucky enough to have this stuff are in charge of doing lab work for the entire district. Hundreds of samples get trucked in, they run them, and have to keep the paperwork straight when the results are sent back. This is difficult for the districts as they have to wait for important information and they can’t just order a repeat lab if needed. The lab guys told us they were trained in Maputo, the capitol city, which was the only place in the country to get such an education. Lab support is in short supply in Mozambique and is one of the major hurdles to building good care networks. FGH is searching for laboratory techs for all the district sites and is finding it pretty difficult.

Today we didn’t see many children. We went to the clinic yesterday and waited on the side bench outside while some other physicians went to see about introducing us. There was a woman next to us with a child on her lap of maybe four or five years of age. He was covered head to toe with small crusty lesions (3-4mm, dark brown to black, scaling, flat macula, in the same stage of development, covering the entire surface of the body including corners of his mouth for all you medical people.) I wasn’t sure if it was a childhood disease like chicken pox or if he was HIV+ and had some opportunistic infection. At any rate, he was laying listlessly in his mother’s lap until we sat down nearby and then he began to whimper. We slowly slid off our white coats, careful not to look him in the eye. I don’t know if it was that or his mother’s jostling, but he quieted down again.

9/12/07: A Funeral

I saw a pick-up truck go by today with a rough wooden coffin in the back. People were sitting all around the edges of the truck, maybe 20 in all. They were all singing and clapping their hands to a beat with mournful faces. One man was standing in the back holding a wooden cross upright on the top of the cab. Many cars were following. People in the streets stopped what they were doing and watched. In the "noticias," we see announcements of the anniversary ceremonies (described in an earlier entry) of people’s deaths. Most of these notices have pictures of the deceased attached and the people in these photos look very young. The announcements describe the sadness of the family at the loss of their loved one and the date and time of the ceremony. Friends and family show up on the appointed day and time. We passed a house while walking one day where one of these ceremonies was taking place. People were drumming and singing in the yard. It was hypnotic. Aguinaldo says that sometimes santaria is practiced at these ceremonies. Or what sounds like a mix of santaria, ancestor worship, and Christianity. The city of Quelimane is surrounding by thousands of thatch settlements. Sometimes in the evenings, we sit on the porch and watch night fall with a stunning swiftness and completeness at about 6:00pm. We can hear drums start up in the distance in the midst of those homes and we wonder what’s happening. They can go on until 1 or 2 in the morning.

9/15/07 Domestic Life....

We have moved in with Dr. Troy Moon, new faculty in Vanderbilt’s Pediatric Infectious Diseases Department. The house is poured concrete and painted white. It sits on a dirt lane off a road in Quelimane. We don’t appear to have an address. The house has a back yard with palm trees surrounded by a wall. There is a ton of interesting fauna. At night, huge bats swoop down from the palms. A friend assures me that they are fruit bats and are not interested in people. There are also large rats in the back. I wish the bats ate rats. We were discussing some system of tying fruit to the rats and seeing if the bats would carry them off. Sometimes at night the neighbor kitty jumps over our wall and chases them. We cheer for her.

Troy has spent the last few years at Tulane in New Orleans. He survived the flood (though his house had some serious problems) AND a tornado that took his roof while he was under it. At some point in the midst of all that, an itinerant rooster made his home in Troy’s backyard and they got to be friends. So now we’re considering getting some pet chickens. We don’t know if the bats and rats would be a problem though. We might teach them to defend themselves against the rats. We have a bathtub sitting in the backyard (randomly). I think it would be a good place to raise chicks if we cover it with chicken wire or something.

There are many bugs around, luckily most have not found their way inside. We leave the screened windows and doors open because the majority of the house is only cooled by fans. It’s not so hot now. I don’t know what December will be like. It’s very different to have the windows always open. You feel a lot more connected to the neighborhood. We hear people passing in the lane and the drums in the distance. You hear roosters crow in the morning. You catch whiffs of smoke from the ubiquitous trash fires. I’m not yet used to it; I still leap up and check down the streets to see what’s burning. I don’t think concrete will burn easily, but all the windows and doors are covered by iron bars which is disconcerting. Also disconcerting is fire among the miles and miles of thatch housing in the dry season. When rainy season arrives, our mosquito nets will have to go up. Many geckos have found their way inside. There are always a few hanging out on the walls. These guys are my favorite and I welcome them. They eat bugs. We’re on the same team. They range in size from really big to "Baby Geck," whom we found in the pantry one night and is maybe an inch long.

Casa de Lua is working out well. I get up in the morning, hop in the shower, which may or may not have water, which may or may not be hot. Every day is full of surprises. We struggle a little with the pump and the heater. Our bath window looks down into the neighbors’ yard. There is often a gray-haired man lying naked on their porch. I think he’s probably demented. He’s only the second gray-haired person I have seen here in Quelimane. I guess that’s not so surprising when you remember that the life expectancy here is only mid-40's. I come downstairs and we make coffee and sometimes toast in a pan on the stove. I’m surprised how much I miss pre-sliced bread, and bread that is wrapped up in plastic before flies get on it. In the mornings, our group has a little breakfast and practices Portuguese for a couple of hours in the backyard before splitting up to attend to various things. The mornings are really beautiful, not too hot yet and very sunny. I have learned a lot about cooking in Mozambique, one of the most important facts is that stoves often are not grounded electrically. My innocent looking toast shocked the fire out of me one morning and nearly curled my hair. For awhile I was only approaching toast or pan handles with hot mitts on both hands. It was really waking me up in the mornings; I didn’t need coffee. Then, we got an empregada who taught me the importance of wearing shoes around non-grounded stoves. I should have known this from high school, but whatever. If anybody’s heart ever stops I’ll know what to do. (Take off their shoes and make toast.) Our empregada’s name is Esmeralda and she’s very nice and corrects our Portuguese. The first day, she took us with her to the market, which is open air with thatch stalls on a muddy plain. There are wooden planks over the ditches and holes and you have to be careful crossing while you are carrying your bananas or whatever. I try to arrrange with her in the mornings what we need her to cook and clean for the day. We decide on a menu, she tells me what is needed, and I send Paulo (who lives in a hut-thing in the back) to the market. We do our best to communicate, but it’s hit or miss what we have for dinner or when we eat it. We ask for it about five, but it’s variable when it comes. I only just realized she doesn’t have a watch and is going by the sun. I think there are some cultural differences as well. Troy bought a couple of nice pans in Malawi when they went for Visas. We only had one tiny aluminum pan before and it’s really hard to make a meal for 7 people in it. The pans he got were very shiny and one had a fluted bottom. Esmeralda kept asking me if they were for cooking. I think she thought they were too nice for that and must be only for serving food. I reassured her that, yes, these were for cooking. Yes, "para coisinhar." Yes, on the stove. I’m not sure I convinced her because when we came home that afternoon, our old tiny pot was bubbling away and she pulled Kevin aside and asked him as well if the new pots were actually for cooking. We mostly eat rice and beans or rice and vegetables and salad. Two of our group are vegetarian, which I think is also confusing to our empregada. Here in Mozambique, they eat a coarse corn flour boiled to make a paste thing that they shape into balls. It’s called "xima" (shee-ma) and you use your hands to dip it into stews and sauces and eat it. Very good if you don’t have silverware. Uncooked, it looks like grits. I boiled some up one morning and left it runny instead of pasty, and added butter, salt, garlic, hot pepper, and cheese. Esmeralda was watching me with concern. I explained I was making something we eat in the states, similar to xima (I was NOT just making a runny mess and squeaking when I got shocked, thank you very much) called grits. She repeated, "hreets? gwits?" I said "quere provar?" (Want to try?). She said she liked them. But really, who doesn’t? They’re a grainy international passport.


Blogger Laine said...

Well, watching a movie or reading a book about Africa is one thing. Reading the account of a member of your family is totally different.
I am amazed at the day to day encounters, the house and yard where you live with all the creatures and, of course, the health situation and the sick who you are trying to help.
Here at home nothing seems eventful after reading your blogs. Anyway, Florida puiverized Tennessee.
Amanda and Thomas had a birthday party-38 KIDS. There are three words to describe it, NOISE, NOISE, NOISE. It started to sprinkle and Amanda moved all the tables inside. They started at the fireplace in the living room and extended and made a big T in the dining room. It was a water party, two kiddie polls, water guns and water balls. One child was in the middle of a pool sporting a (I did not know of this)waterproof cast. I wondered what happens to children who break their bones in remote parts of Africa. And lastly, Ella was bitten by a mouse. They have three cats and one of them had caught a mouse in the yard. Ella ran over: the cat dropped the mouse and Ella extended her hand toward the terrified mouse who promptly bit her. The pediatrician said that if it does not get infected, she will be fine.
In closing, I think that you, no matter where you live or how much time passes, will from time to time at twlight hear the drums of Africa.
Take care.

September 16, 2007 at 8:37 PM  
Blogger Unknown said...

How odd that my mom is the other comment here so far...

I've been covered up and just now had time to read your blogs. I have to say I admire that you take the time to get so much of your experiences recorded in writing. It is not only a joy for your friends and family to read, but I'm sure detail in which you attend to recreating your experiences will one day bring it all so vividly back to you. Photos and videos can only do so much...

Here's to continued energy to face each new adventure.

September 27, 2007 at 2:55 PM  

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