Sunday, January 30, 2005

Good News and Bad News

A couple of weeks ago, at the same moment when the Minister of Health was giving a press conference here about the laudable progress the government is making in expanding HIV treatment and providing free anti-retrovirals across the country, a few blocks away a young man in his mid 20s was jumping off a 10 story building to his death. Friends and relatives attributed the suicide to his recent discovery that he was HIV positive.

Surreal juxtapositions like this are common here. We are supposedly awash in donations from PEPFAR, from the Global Fund, from the World Bank, but complicated funding mechanisms and reporting requirements mean that it takes months or even years for the money to be turned into drugs or infrastructure improvements. So even as we read that the Global Fund money has arrived, the local health departments here are asking us if we can help procure medications to prevent mother-to-child transmission of HIV and malaria for a few more months. Meanwhile, Mozambique’s yearly debt service (about $150 million dollars) is enough to buy drugs to treat over 200,000 men, women and children with HIV. Right now, only 8,000 are being treated, but the rapid scale up plan calls for access to drugs for those 200,000 within 5 years.

Often the surreal moments reach into my daily life. Last week I was flagged down while driving past what looked like a broken down machibombo (small bus). The bus had been emptied and the passengers gathered around it, spilling into the road. The only white man in the crowd approached us and explained that there’d been an accident, the bus had hit a young boy, he was unconscious but still alive. I got out and before I could walk 10 feet, a couple of guys were half carrying-half dragging the limp child to my car. We opened the back, I tried to make a flat surface big enough for him to lie down, and we raced off to the nearest hospital, about an hour’s drive away. Once I had time to assess him, my heart sank. He had a pulse and was breathing, but he was completely unresponsive and his pupils were fixed and constricted. There was no flicker of life left in his motionless eyes, only his hands twitched occasionally with involuntary posturing. Outwardly, he had a small laceration on the right side of his scalp, but otherwise looked completely unscathed. We are fragile creatures.

He may not have survived even in the best of circumstances, but here, his chances were nil. At minimum he needed a neurosurgeon and the nearest one is 600 miles away. Still, his chest rose and fell at regular intervals and his heart continued to beat, not quite catching on to the futility of its continued service, still on the powerful automatic pilot of the deep brainstem.

Most disturbing to me about the whole experience was the reception we got when we rolled up to the emergency ward. I went in first and asked for a stretcher, and after a couple of minutes was able to get an orderly’s attention. It was late afternoon and only a few people were milling around. One man was lying on a bench behind a screen with labored breathing and desperate, hypoxic eyes, a couple of others sat patiently on another bench across the hall. A receptionist was giving all his attention to the mound of paperwork in front of him and was not going to be distracted. Finally a nurse noticed me and said “put him in room two.” As I was wheeling the bed into the room, I noticed a man in a white coat and stethoscope strolling by. Repeated “excuse me sir”s got no response. Finally, I walked in front of him, said “good afternoon,” introduced myself, and explained the situation. He walked into the room where the nurse was starting an IV, and said simply, “put him in the surgical ward” and walked out. I stayed with the boy about an hour longer, as he was transferred to a regular hospital bed, hoping his parents would show up and I would have a chance to explain the hopeless situation. Someone had gone to tell them that we were taking their gravely wounded son to the Chimoio hospital, but from their home about 80 kilometers away, it might take them hours to arrive on public transport.

The next morning, I went to work in the Chimoio HIV treatment center “day hospital,” about 100 yards away from the emergency ward in the hospital complex. It was also a tough day, we saw the malnourished child of a mother with HIV. The five month old weighed only 7 pounds and wasn’t breastfeeding. We saw a skinny 15 year old with big frightened doe eyes who was just diagnosed with HIV and was sick with malaria. But we also saw 10 or 11 people who were healthy, gaining weight, getting the treatment they need from attentive docs, caring social workers and kind peer-activists. I wrote an email to some friends commenting on the amazing difference that basic infrastructure and a few thousand dollars makes. The reply from a doctor who worked here for two years was more accurate: “a little remuneration gives one's selfless side the ability to come out and play.” In absence of doctors, nurses, basic supplies and medicines, beds and equipment, the hospital staff is continually beaten down and has come to know that there’s not much they can offer— everyone’s overworked and disappointment is constant. Those are the perfect conditions to foster the inhumanities that I witnessed. But it’s also surprisingly easy to turn the equation around. Every month now, we’re putting about 150 new people on anti-retrovirals at the two day hospitals we support. For those patients and their families, it may be the first time they’ve gotten attentive, comprehensive medical care from the down-trodden health care system.