Heard on the Floors #4 – Uganda

In commemoration of the upcoming World AIDS Day on Thursday, December 1, we’ll be thinking about HIV/AIDS this week. Below, a reflection from Uganda written by Nelson Chiu, a fourth year at NJMS.

Ward 4A is the Infectious Diseases in-patient ward. As you enter, you pass through a long corridor that looks like every other wing in the hospital, with a nurses’ office, doctor’s office, tea room, pharmacy, and laboratory. At the other end of the hallway, you come into an atrium which separates the men’s wing on the left with the women’s wing on the right.

Immediately after stepping into the atrium, you realize that this is not a normal wing of the hospital. Patients are packed into the wards like sardines, with some spreading some sheets on the floor in between beds and using it as a make-shift space due to the overcrowding. Tuberculosis patients are placed in the open-air atrium, so as to isolate them from the other patients. The efforts are probably futile, however, the area is so cramped that nearby guests and attendants readily breathe in the bacteria-filled air.

As you walk into the women’s clinic, the first thing you notice is the silence. There are no cries, just silent, raspy breathing. As the intern doctor, you walk to the first bed and introduce the patient. Because HIV/AIDS is still a stigmatized disease, the patient is introduced as “seropositive” so that the surrounding patients cannot hear. Not that it makes a very big difference, as 90% of the patients on the ward are seropositive. In the US and Europe, we begin treating HIV/AIDS patients with antiretroviral therapy at a CD4 count of 350 or lower. The Ugandan standard is 250 because of lack of resources, but in the ID ward, patients present with counts of 50, 20, 4, and even 2. This would be considered late-stage disease in the West and a rarity to see, but patients are arriving at Mulago with little or no treatment, and a low CD4 count is the norm, rather than exception.

HIV/AIDS weakens the immune system, and it is the opportunistic infections (OIs) which inflict the most damage. Almost every patient is suffering from multiple OIs. On one female patient you can see candidiasis on the base of her tongue and roof of her mouth, presenting as a white carpet-like growth. Another has a large, baseball-sized wart growing on her forehead, possibly caused by herpes. Of course, many have tuberculosis, mostly pulmonary, but also presenting in various other parts of the body. But for many, the infections can’t be seen or heard, and are infecting the central nervous system.

Meningitis is the most common OI seen in the ward. The covering of the brain, the meninges, becomes inflamed due to viral or bacterial infection. For most individuals without AIDS, the immune system does a tremendous job of protecting against invaders which can cause meningitis. But for those weakened by AIDS, any household bacteria or fungi can invade, and the symptoms are sudden and severe – blinding headache, fever, seizures, altered mental status, and impending death. Even the best available antibiotics in the West are not particularly efficacious against the common meningitis-causing pathogens in AIDS patients, and as a physician in Uganda, you do not have access to many drugs. Antibiotics and anti-fungals are administered and lumbar punctures (spinal taps) are given, but many of the patients do not have a very good chance at survival. Even if they recover somewhat and are discharged, the relapse rate is extremely high and survival rates grim.

But you are an overworked young physician and do not have time to ponder these spiritual and philosophical issues. You move on to the next patient, trying to manage the massive room full of dying patients, hoping to save a few and prolong or at least make more comfortable the lives of the rest in your ward, with what little you have. Half the time there is no anesthetic available on the ward, and you have to perform the lumbar punctures without it. There are barely enough clean gloves and needles for you to draw all the necessary blood from the seropositive patients, some of whom are combative and increase the chances of you accidentally sticking yourself with the needle, something which has already happened a few times in your career.

Your thoughts are interrupted by a loud, howling scream. You rush over to the men’s ward. A gentleman is lying on the floor on a makeshift mattress, with drool and vomit on his right shoulder. His eyeballs are turned upwards in his sockets, and he is screaming at the top of his lungs. His body shakes uncontrollably, and his hands claw into the air. The screaming turns into moans, final cries for help. As you approach him to see what is wrong, his body snaps toward you. You jump back just and time and call for the senior health officer. The patient has late stage rabies and has completely turned deranged. You watch as the senior officer dons gloves and sedates the patient. Before you arrive for rounds tomorrow, he will have passed away. Remembering the moanings and cries, you realize that it is probably for the best, and say a quick prayer before tackling the next roomful of patients desperately needing care.

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