CIDRZ has over 500 employees. While many of them spend most of their time in the office, there are many more who work in the clinics, in the hospitals, and even door to door. Each morning at 8:30 am, a fleet of minivans and SUVs fills with people, clown car style, and they head out in every direction towards the clinics. Most of these are located in what’s known as compounds, essentially slum neighborhoods. Some have electricity, some have water, some do not. The houses are placed haphazardly, some along the road, others back from the road, in clusters, all alone. Some houses seem to have been thrown together with whatever building material was available- some concrete here, some corrugated metal there, a bit of wood in places.
The roads to these compounds start out well paved, but as they reach many of the clinic areas, pavement turns into rocky, rutted, hard packed dirt road. Sometimes a marketplace will be placed seemingly in the middle of the road, yet the car will somehow makes its way through the masses, as if going for a browse through the market itself.
Driving through one of these is almost an over stimulation of things to look at. Little thatch-roofed stalls manned by women wrapped in their colorful chitenge. Piles of shoes for which you must sort, and would be lucky to find a pair. Ever wonder what happens to all those clothes you donate to Goodwill? They’re here. Wrinkled donated clothing from the states hanging on hangers placed every which way across the stall, sporting such sayings as “Everyone Loves an Italian Girl” and “Suessical the Musical.” Dust sprinkled vegetables, potatoes, tomatoes, yucca, and large green leafy vegetables of unknown sort sit in defined piles, marked with hand written price signs. Plastic buckets, brooms, and dustpans. There are extra dusty portions of the market selling packages of charcoal. If you looked hard enough, you could probably find almost everything you need there, at far more reasonable prices than the imported South African supermarkets. Weaving between these booths are the Zambians wearing most clothing like the ones for sale, the women with the added accessory of a baby wrapped tightly in a chitenge on their back, and a basket balanced firmly on their heads. The soundtrack to all of this was the bouncing African music the driver had blasting, with the added bouncing of the van itself along the rutted roads. The masses parted, miraculously, for our van, and on the other end was the sign for the Ministry of Health clinic.
The clinics remind me of the many clinics I saw in Panama. Yet there were differences too, some better and some worse. As in many developing countries, they are compounds of simple concrete and brick buildings, some with large waiting areas, some with cluttered hallways, but most all of them are filled with people waiting to see a health worker. CIDRZ has helped to revolutionize HIV treatment here. Many of the clinics now have new buildings devoted completely to ART (anti retroviral treatment), where there was no building, or treatment, before. It is really only since 2003 or so that such treatment has become so widely available. They streamline the process well. The hall of the ART clinic takes you down an assembly line of all the services offered. You start with the VCT area (voluntary counseling and treatment). Then there is intake, exam rooms, adherence counseling and pharmacy. At the end of the hall, there are always the CIDRZ data people, in rooms filled with computers where you would never expect to find a computer. Their teams works to document the massive amounts of data produced by the more than 150,000 on ARVs (anti retrovirals) for the ART scale up project alone, not to mention a comparable number of mothers in the PMTCT (prevention of mother to child transmission) and pediatric HIV programs. They keep tabs on every single CD4 count, who is failing treatment, who has not showed up for follow up appointments. At the very end of the hall, the community team helps track down those who have not come back. Floating between these rooms is the QA/QC nurse (quality assurance/quality control), who mentors the clinicians, does chart reviews, and follows up on patients failing treatment.
All of that is just the ART clinic area. Each clinic compound has a MCH (maternal child health) area as well, with an equally crowded hallway of waiting pregnant moms, and an equally if not more impressive computer system to keep tabs on them. Perry, the America doctor in charge of the PMTCT program, can sit in the CIDRZ office, and monitor via his computer exactly how many women were seen in any given clinic that day, how many tested HIV positive, and how many were sent to the University Teaching Hospital (UTH) for any obstetrical problems.
I got a tour of the labor and delivery wings at many of the clinics as well. While many women probably deliver at home, many deliver at the local clinics. It is far fewer who deliver at UTH. In Panama, my impression of Labor and Deliver compared to the states was certainly barebones. But this, blew all of that away. In one clinic, we were brought to a simple room with four bare stretchers. One woman lay wrapped up in a sheet, the only sheet I saw in the whole room. She looked barely 14, but she was all alone. The midwife said they don’t allow any family in, and encourage them to go home in fact to cook food for the mother once she is finished delivering. There are certainly no monitors. A shortage of gloves. I am not sure if I saw oxygen. The stethoscopes were the old fashioned megaphone looking contraptions, which you place directly on their stomach and place you ear to. This was for listening to fetal heart sounds. This is birthing as it has been done for centuries, perhaps even slightly better.
My clinic visit on Friday led to my taking the unexpected role as pediatric ART clinician for the morning, with some help of course. There are very few doctors. Every clinic has at least one clinical officer (CO), which is the equivalent of our PAs back in the States. Together with the nurses, they run most of the care. The doctors spend most of their time in the regular outpatient services side of the clinic, and are only called in for very complicated cases. After our clinic tour, we were invited to watch one of the COs see the pediatric ART visits. After a couple of visits, he asked me if I wanted to try. So suddenly, there I saw, sitting at the desk, pen in hand, flipping through the file, asking a little two year old girl’s mother about which medications she was on, how she had been feeling, doing a quick physical exam and making a plan for follow up. I didn’t know when I started the morning, but now I do. Using percentage CD4 count rather than absolute count for children, first line pediatric ARVs, how to dose them (there’s a useful weight chart on the wall), other supplementary medications like septrin, multivitamins and iron, and when to make follow up appointments. One 10-year-old boy came in with a plan to start ARVs that day. He had been seen two weeks previous with a falling CD4 percentage and had various labs drawn in preparation for beginning meds. During the history his mother mentioned that he had developed a dry cough. I’m not sure that his lungs would have been listened to if I had not been there, because I’m not convinced that the CO had a stethoscope. His physical exams were short at best. But I took a listen, and his lungs sounded junky. So together, we made a plan to get him a chest xray, throw him on some regular antibiotics and start his ARVs. What’s common is still common, the most common causes of pneumonia in HIV patients are the most common causes for the general population. But I wonder if we’ll find that he has something more complicated, like PCP pneumonia or tuberculosis.
Disclosure of HIV status to children is another issue that left me thinking. Part of the regular counseling is asking if the children understand that they have a chronic disease, have HIV, what it means. I did not meet one who did. Many of the children I saw were young, ranging from babies to 10 years old. The mothers stated that none of them knew, that they thought taking pills was the norm. There was one 13-year-old boy who came by himself. We asked him if he understood why he was taking pills, why he came to clinic, and he said no. We asked him where his parents were. Mother dead, father at work. We asked him to return to his next appointment with his father, so that we could begin the delicate topic of disclosure with the counselors. But really, how could he be 13 and not understand his status?
The “what’s going on?” moment of the morning was with a 7-year-old girl, who came in with a woman and a baby. We always inquire after the mothers when the children come in, because they too should be enrolled in the ART program. We asked this woman if her baby was okay, she smiled and said yes, we asked if her husband was okay, and she said yes, we asked if she uses condoms with her husband, to which she shyly replied no. At this point, we thought we would have to get into a counseling session. And then she said she was HIV negative, to which all of us responded “huh?” But the question, “is this your daughter” quickly clarified that this little girl was in fact her niece. Her parents are dead, and she is one of the millions of AIDS orphans. Now I know not to make any assumptions.
My mind is chock full of these experiences, these impressions. It’s only the first week. I have not even begun my project yet. This is just a taste of all that is going on here. On Monday morning, I will begin to learn about my project. From what I know now, there are two clinics that are piloting the integration of all services- regular outpatient services with ART and tuberculosis care. Up until now, they have been very much separate, if only because the massive amounts of funding which have come in the past few years for AIDS in Africa led to the rapid creation of the self standing ART clinics. Now we are trying to integrate those services with everything else.
My week of understanding life as a Zambian a little better ended with life once again as a mzungu. After work, there was happy hour (which turned into happy three hours) at the fancy South African bar/restaurant at the Arcades Mall, with about 20 expats from CIDRZ. Seeing a bill for 780,000 kwacha made me laugh. The evening continued with the new Batman movie, opening weekend here, only one week after the States. Impressed? It was a little bizarre standing in the movie theater which could have been any Loews back at home, meeting a friend of one of the CIDRZ people who was also class of 2004 at MIT and lives in Boston. Once again, I had to remind myself where I was.
This morning I joined in to the ultimate Frisbee games that happen every weekend at the American School outside of town. Another mzungu event for sure, but a great way to meet more people. Made me miss my ultimate buddies back in Cambridge, but it was a great game and a great workout.
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