Closed Doors Have Opened Others: Part I

Katrin Sadigh, MD

Rain, and plenty of it, has been cast as the main character of our first week in Harare. Not the kind of rain that even the local people expect during the rainy season, its brief, sudden arrival muddying the streets though with hints of blue skies in the distance. Now, the cloud cover does not dissipate, issuing any manner of rain, torrential or mist, overnight and throughout the day. It seems fitting somehow, as I awake each morning twisted in stiff white linens, stenciled with “University of Zimbabwe” in black letters, my dreams heavy with what I fall asleep reading. My phone is newly outfitted with a Zim SIM card and an expensive data bundle, transmitting news line after news line about Obama’s last days in office and the upcoming inauguration ceremony.

I haul myself out of bed with the thought of the South African coffee bean awaiting to be seeped a full four minutes in the French press that Sarah and I found in the local shops. As we collect our stethoscopes and head across the street to the main hospital, I feel relief that Sarah and I have a place here, as a fourth year medical student from Vermont, and a fellow in Infectious Disease from Massachusetts, respectively. The medical team of the C6 general medicine ward greets us with smiles despite being post-call. We join the circle around a patient bed, listen to the junior members of the team present the story, with the senior member extracting salient points to discuss. He cites well-cited reviews in the New England Journal of Medicine and weighs costs and testing feasibility with standard of care, in a didactic model that is well known to us. Then the other questions, where does the patient stay, how long was he at the community hospital, what is his HIV status, remind me that while the context may change, a focus on patient centered care should not.

Dr. Katrin Sadigh, left, working with a medical team at Parirenyatwa Hospital, Harare, Zimbabwe

And despite a large census of 40-50 per medical team, they draw the curtains, drape sheets during the exam, spend precious minutes explaining the plan and discerning patient understanding. We move from room to room, with a nurse wheeling a metal cart labeled “Doctor’s trolley,” that contains medical records and prescription pads. One of the team members often falls behind to perform a simple procedure such as a peripheral line placement as the next patient is greeted. Each room consists of four hospital beds, one shared bathroom, and a large set of windows, wide open and stickered with a warning about tuberculosis. Cleaning staff mop the floors daily, adorned by a bed and a plastic side dresser containing personal effects, usually a change of clothes in a plastic bag, bananas and fruit juice. Family members abide by a strict visiting policy, between 1:00 and 2:00 PM, though the teams often make time to meet privately when necessary.

My role largely has been one of an observer. I ask why so many young patients have atrial flutter (because of the high prevalence of rheumatic heart disease), what labs are available and how quickly results are obtained (HIV viral load costs anywhere from 35-95 USD with a turnaround time of 2-3 days versus no costs but 4-6 weeks to process at the hospital Opportunistic Infection clinic), the cost of a CT head (170 versus 190 USD with or without contrast), and how people manage to pay this price (with great difficulty, “mobilizing” funds). Filling in the details of this medical and social context has brought more relevance to my differential diagnosis (tuberculosis for acute abdomen), vitamin B12 as the primary suspect for macrocytic anemia (because malnutrition is real, especially in prisoner populations, and especially in a country that has had little rain for most of last year), and has provided a framework for understanding standard guidelines of therapy (use of integrase inhibitors for ART is third line here due to high cost burden).

Part II will be posted next Friday.


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