It’s been a hard day’s night

It’s been a tough week for me, as I’ve come face to face with the harsh realities of life in resource-limited settings. It started last week when I learned a whole lot about how governments figure out what quantities of HIV/AIDS drugs to procure for their children. So many of the tools that developed country government use — things like patient data, consumption data, health information management systems, national ID numbers — don’t exist in many African countries. And while this doesn’t sound like such a big deal, look at it this way: if an HIV-positive baby isn’t able to access the medicines she needs because her government couldn’t forecast its national medicine requirements properly, then that baby is probably going to die.

Now, part of my job is to help increase the number of local health clinics that offer pediatric HIV/AIDS services to its clients. At the moment, many people here need to walk for hours to get to a hospital that can care for their HIV positive children because the much closer health clinic isn’t equipped to do so. But, lemme ask you this — how can I in good conscience do my job, if there’s a pretty darn good chance that these clinics will run out of children’s HIV/AIDS drugs? How can my work be ethical? You cannot start a child on a cocktail of anti-retroviral drugs (ARVs), only to switch them to another cocktail because the original regimen stocked out. That child also cannot just stop taking her drugs and start up again when the drugs are back in stock. There are so many consequences to these actions, including the risk that the child develops a resistance to the drugs and has to start on her “last resort” drugs, which means she probably doesn’t have much longer to live. And the more individuals who develop drug resistance, the more society as a whole becomes resistant. In America, you have a bajillion different drug cocktails to choose from, so building up resistance just means you can switch to another then another then another drug regimen.  In Lesotho, you essentially have a “first line” and a “second line” regimen. That’s it. So if your nation’s population of 1.8 million is developing resistance to your first line regimen, you’re screwed. Lesotho has to take it so seriously that if any doctor wants to move a patient to the second line regimen, the request needs the approval of a national committee.

It could very well be argued that it is unethical to begin a child on AIDS treatment if you know that child won’t be able to access her drugs on a regular basis. So, if I’m supposed to be increasing the number of clinics that can initiate a child on treatment, and I know that most existing clinics are running out of children’s drugs, what do I do?

 

Questions

I’m wrapping up my fifth month in Lesotho and am just now feeling like I understand the work I’m supposed to be doing and am becoming effective at it. This past week has been a hectic one, as I’ve been charting out my Q3 and Q4 workplan, but finally, finally, I feel like I’m getting somewhere. It’s frustrating that it’s taken five months to get to this point and I wish I had done this kind of planning three months ago … but at the same time, I don’t think I knew nearly enough back then to do it. Still not sure I do. To give you an idea of what’s slowed me down, here are a few questions that have been posed to me or that shed some light on what it’s like to work in HIV/AIDS in a resource-constrained environment that still bears a stigma towards this plague:

• What do you say to an HIV-positive woman who says her husband will beat her if she tells him of her status?
• Is it even possible to combat HIV/AIDS when the local radio stations run advertisements for herbal drug that cure AIDS?
• How do you handle a situation when the only generic drug manufacturer of a certain children’s drug decides to stop producing and it means that a 3 yr old child now has to take 5 tablets at a time, twice a day?
• When an infant’s HIV/AIDS test result can take up to four months to be returned, at which point that baby has probably died, where do you start?
• How can you provide life-prolonging ARV drugs to children when they can’t even afford the transportation to their nearest health clinic? Or when they have to walk 4 hours to the clinic? Or when the river floods and can’t be crossed for a month?
• What value do you put on life when the majority of your weekends are spent at funerals and in cemeteries that stretch for a mile along the road?

I know I don’t have all the answers and I probably never will. But five months on, I know there are solutions, imperfect though they may be.