human resources link

October 6, 2004: Perspective

James Steinberg illustration

Illustration by James Steinberg

Faces of an epidemic
A doctor goes from treating diplomats’ sprained ankles to caring for Africans ravaged by AIDS

By Lawrence Hill ’63

Larry Hill ’63 is an internist who has worked with the U.S. State Department since 1991.

The little boy was indeed little. We didn’t have a scale but I estimated that he was 2 years old and weighed 15 pounds. His aunt, who brought him to the small hospice where I was volunteering, across the highway from the cement factory some 10 miles south of Lusaka, Zambia, told us he was 4. The boy’s mother died months earlier, presumably of AIDS-related tuberculosis. On examination, the boy, whom I will call Tembo, was fiery hot and completely unresponsive. His neck was board-stiff; scratching the sole of his foot made his big toe go up, not down as it would in someone without severe brain or spinal cord disease. There was no escaping the diagnosis of meningitis in a child with AIDS. The meningitis could be caused by TB, by the now all-too-common – thanks to AIDS – cryptococcus fungus, or by a more garden-variety bacterium.

In a developed country, Tembo would have been transferred immediately to an intensive-care unit, and evaluated with an MRI and then a spinal tap. The fluid would have been analyzed to identify the causative micro-organism and specific treatment would have been directed to the illness. The first day in the hospital would probably generate, in the United States, a bill of $20,000 or more. Tembo, because of his far advanced immunodeficiency and malnutrition, almost certainly would have died anyway. The entire annual budget of this hospice in Lusaka, which had a constant inpatient census of 30 and an outpatient census 10 times that high, a rudimentary lab, and even more basic pharmacy, in addition to nearly three dozen employees, was $60,000. It was run by a 23-year-old volunteer from North Carolina who had come several months earlier to bridge her college and medical school years but who was soon thrust into the slot of chief operating officer when the European nun who had been running the place departed unexpectedly.

We had no spinal needle, let alone an MRI scanner, and treated our patients as health care workers of yesteryear did, using education, experience, and guesswork. We used antibacterial agents and drugs. Tembo’s fever went away, but he never awakened. He died on his fourth day in the hospital.

My home this year has been South Africa, a much wealthier country than Zambia. Here I attend clinic at Kalafong Hospital, a large public facility in Atteridgeville, a huge, poor township just outside Pretoria. The hospital is one of the sites of the rollout – long delayed by political and economic hurdles – of anti-retroviral agents (ARVs) for the treatment of HIV/AIDS. Cecilia, a gaunt 38-year-old single mother of two, told me the following story: In 1999 she was abducted by three men as she was on her way home from work as a domestic servant. She was blindfolded and imprisoned in a room far from her home. During the next three days she was repeatedly raped. Almost unbelievably, two of the three men used condoms, presumably to protect themselves from her. The third kidnapper did not, and six months later, Cecilia was found to be HIV-positive.

By April 2004, her CD-4 count, the measure of how advanced the disease is, had dropped precariously. Thanks to the availability of ARVs at no cost to her and an affordable cost to the government, Cecilia began the three-drug cocktail most commonly used around the world. Since then, she has gained five kilos and is caring for her children again. It is too early to say how long the ARVs will help, but most of us think there is a very good chance that Cecilia will live a normal life-span, an unrealistic thought only a year ago, when ARVs were beyond the financial ability of all but a few South Africans.

At my graduation in 1963, Princeton President Robert F. Goheen ’40 said something to the effect: “Don’t do anything for more than 15 years. Life is too short.” I took that admonition to heart a bit more 15 years later when I gave up my internal medicine/oncology practice in Eureka, Calif., and joined the State Department. I had spent a couple of years with the Peace Corps in Venezuela in the late 1960s and so already had a taste of peripatetic medicine. My wife and I had lived in Mali, Bangladesh, and the Philippines before I did a brief stint at the mother house in Washington and we moved to South Africa. After four years of clinical work there and in a dozen other African and Indian Ocean countries, I was granted a sabbatical in Pretoria, with my only charge being to learn everything I could about HIV/AIDS in Africa – from the clinical, research, social, political, economic, and cultural standpoints. The sabbatical soon will be over. I’m being sent to Beijing, where I again will care for Americans with sprained ankles and diarrhea, but also will play a role in coping with the burgeoning AIDS epidemic in the world’s most populous nation.

The statistics that define the pandemic are familiar to anyone who reads a newspaper. Sub-Saharan Africa has more than 30 million HIV-positive citizens, virtually all of whom will need ARVs or will die prematurely. South Africa, with 5.2 million such patients, more than any other country, registers some 1,000 deaths per day from AIDS. The average life span in Southern Africa, believed to have reached over 60, now is, or soon will be, less than 40. Where massive overpopulation was the great fear a few years ago, the populations of several southern African countries will drop. Perhaps most distressing is what this awful disease is doing to children – UNAIDS, the Joint United Nations Program on HIV/AIDS, recently announced that there are more than 1 million AIDS orphans in South Africa. The planet has never before seen an epidemic like this one; one can only pray that it never will see another.

Today, there are many more Tembos than there are Cecilias – only a tiny fraction of those whose lives could be saved with modern medicine are being saved. I am honored to have played a role in those two lives and to have been involved with those of many others as they battled this disease that wasn’t identified until 20 years after I graduated from medical school. For a wizened internist whose 40th Princeton reunion is history, I’m a very lucky man. end of article


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