One of the most heart-rending patients I saw was young man with HIV/AIDS. He had initially presented to the clinic on 12/10 with advanced disease (for the medical folks his CD4 count was 3) and was started on antiretroviral therapy (HAART). He came back to clinic in January dehydrated with diarrhea, some fairly advanced skin ulcers, cough and fever. I remember the morning he arrived he was laying outside the clinic on a mat an hour before opening, I could tell from a distance that he was incredibly emaciated, I went over to make sure he was okay, and this man, despite his illness gave me the sweetest smile. He continued to have such a warm smile throughout the few days he spent on observation with us while receiving IV fluids and antibiotics, and gradually improved though he was still very weak. He was discharged on home-based care and I walked with the community health workers to his house a few days later to see how he was. He continued to be incredibly cachectic and weak, but was interactive and eating some. We were able to clarify some of the medication regimens for the family and asked them to come back to clinic the following day. It was incredibly humbling being in his home. His wife was so happy we had come; her generosity was overwhelming, she gave us a generous basket of produce from her garden. I found out 3 days later that he had passed away at home. I felt overwhelmingly sad, and I must confess, still have lingering questions about the best plan of care. Would his course been different had he been at a major medical center? This is a question I will always have to wrestle with. In the course of the month I have seen a lot of HIV/AIDS patients, most of them have been amazingly well, living productive lives on HAART. Several at one stage or another have had immune systems as weak as this man and have recovered remarkably. There is so much hope here, but for those that do pass, like this one, are still devastating for the families and health care workers. I consider it a huge privilege to have known him and his family.
This case is just one on the spectrum of patients I have seen this month. Daily we've seen patients for a range of medical needs including wound debridement, motorbike accidents, sickle cell anemia, along with a range of infections I rarely see in the US: tuberculosis, brucellosis and of course malaria. I've helped deliver a few babies and am in awe of these women who endure childbirth with no pain medicine and very few creature comforts. I have mostly worked in the outpatient department with the clinical officers, but also spend some time in the maternal and child health room on busy days helping with prenatal care and well-child visits. One of the greatest joys has been working with and investing in the clinic staff. I have learned a lot from them about taking care of patients here, and also try to share knowledge about up-to-date treatment guidelines, management of chronic illnesses and broadening their differential diagnoses. Many have family elsewhere and living here is not without sacrifices, so we also just enjoy spending time together outside of work. Leaving Lwala is definitely bittersweet, the month has not been without frustrations or times of loneliness, but I am really sad to leave people here. I take with me lifelong lessons, not only on how to be a better individual clinician, but also in thinking about how to design systems, as well as invest in people to help effectively improve health in resource-poor settings.