First few days in Tugela Ferry

(I’m a little behind on my postings, but hoping to catch up!)

After a poor night’s sleep, I awoke to attend the Thursday morning doctor’s meeting at Church of Scotland Hospital. Here I got to meet the inspirational doctors I had read about in Shattered Dreams? An Oral History of the South African AIDS Epidemic (I recommend this book!) Dr. Tony Moll has worked at Church of Scotland Hospital since the beginning of the AIDS epidemic. He practiced HIV care when it consisted of helping people die, through the frustrating period when the government denied provision of antiretroviral therapy through the public health system, and presently, when ART is available even with persisting resource limitations. At the doctor’s meeting, we discussed how to reconcile the standard of care accepted worldwide with the resource limitations in Tugela Ferry. Government guidelines, for example, make ART available to any patient with a CD4 count below 200. The standard in developed nations is to start at 350.

After the doctors’ meeting, Sheela (Yale infectious disease fellow) then took me for a tour of the hospital. The wards are long single story barracks, with windows opening onto open-air courtyards separating the buildings. Wards include psychiatry, surgery, male medicine, female medicine, male tuberculosis, female tuberculosis, pediatrics, maternity and casualty (emergency). We went into the female TB ward, largely for women co-infected with HIV and TB, and saw my roommate Monica struggling with blood cultures drawn from 5 or 6 of her patients. About 20 patients lined both sides of the ward, with 3-4 feet, and no barrier, between each bed. A cross-breeze caught the curtains lining the open windows. There was a smaller section in the back walled-off for cohorting patients with drug-resistant TB. Both multi-drug resistant TB and extensively-drug resistant TB have surfaced in Tugela Ferry, which is a focus of Yale’s research. Ironically, isolating the drug resistant patients behind a wall, though important, reduces open-air ventilation in the ward, which has been shown to reduce hospital transmission of TB. For contrast, at Yale-New Haven Hospital any patient suspicious for active TB, drug resistant or not, is given a negative-pressure single room so that the droplets do not escape.

I find myself making a lot of comparisons between conditions here and what I’m used to in the US. Though I have now spent a few years working in hospitals, I am not used to seeing so many chronically sick people – wasted flesh, dull eyes – together in one long open ward. It is now rare that HIV positive patients in the US get to this emaciated state. It is not what I am used to seeing.

But we adapt quickly. My second day in Tugela Ferry I rounded in the Philanjalo Hospice. The Hospice was originally created when there was no room for the dying AIDS patients at Church of Scotland Hospital. At the Hospice, AIDS patients were cared for together, with the goal of achieving a dignified, comfortable death. Now, the Hospice is a “step-down” unit for patients who need a little more inpatient time before they transition home. A common reason for admission is to be monitored for adverse reactions while initiating ARV therapy. The Hospice is a symbol of the evolving AIDS epidemic in South Africa; it was created to help people die, and is now being used to initiate treatment.

The pace of care and recovery at Hospice is slow. Since most patients are sub-acutely ill, it is sufficient to round only twice a week to monitor their care and alter their medications if necessary. It is a healing place, with large open windows and views of the Tugela River. Rounding with Scott, we visited each patient with ample time to ask, through the nurse’s interpretation, how the patient is doing. We focused on the physical exam. I saw more physical exam findings my first day than during most of my rotations at Yale. Though most of the patients were malnourished, I learned to look for subtle differences. Are the patient’s legs swollen because of low protein? Do the ribs prevent my stethoscope from lying flat on the patient’s chest? How is the patient’s energy? I learned that even cachectic patients can flash brilliant smiles, showing me the spark of their humanity.

“What I’m used to” is rapidly evolving.