Dealing with death and breaking bad news are among the more difficult aspects of work as a Doctor. Unfortunately here in St Francis it is something you have to do a lot. Death seems to come in waves after a couple of weeks of few deaths suddenly a glut of patients are dying. It seems every few minutes you are taking a relative aside saying ‘I am sorry your father/sister/husband has just passed away’ or ‘I am sorry your mother/brother/wife is very sick they have pneumonia/meningitis/renal failure (generally secondary to HIV) we are going to give them the best medicine and care we can but I think they are going to pass away unfortunately’.
Then there is breaking bad news to the patient themselves. Recently I had a man present with massive right leg swelling and what he claims was a short history of poor urinary flow. A rectal examination reveals a rock hard prostate, blood tests show his kidneys are impaired and an ultrasound reveals in addition to his prostate mass he also has a mass in his bladder. The right leg swelling is secondary to obstruction of lymph drainage by these cancerous masses.
He is a happy cherry man in his 60’s, that is until I try to break as gently as possible (how can such news be termed gentle) that he has advanced prostate cancer and unfortunately there is no treatment we can offer save from pain relief (even that we don’t have a lot of) and a suprapubic catheter if he goes into urinary retention. At that point he breaks into tears. I feel utterly helpless to offer him any comfort, at least if I was his GP at home I could ask him to come back in a couple of days to talk some more, to come if there is any problems, get the hospice involved if appropriate, could communicate more effectively with him without the language barrier. Instead a couple of hours later he is packing his bags to go and I probably won’t see him again. The tragedy of this mans case is that he had previously presented to another hospital and was not diagnosed.
The same day I have to tell a young man in his 30’s some bad news. He is a father of young children, a farmer by profession, HIV negative. He has just presented with abdominal pain and swelling. His liver feels like a massive irregular shaped rock has been transplanted into his abdomen. His abdominal swelling is caused by haemorrhagic ascites (bloody fluid). His diagnosis is Hepatocellular carcinoma. This is a common cancer is this part of Africa particularly in men aged 20-40. The prognosis is bleak. Again I have to explain the same spiel, I am very sorry etc, etc.
Sometimes such conversations seem to pass by in your head without thinking too much, become the same as doing a procedure or writing a prescription. It’s easy to forget that these people are somebody’s husband, father, brother or son. It is also easy to forget that their death particularly if in hospital will put huge financial strain on the family, an income earner may be lost and it is much more expensive to transport a dead body back to the village than a live one.
Death is commonplace here and as such is dealt with differently in the hospital. Staff members often seem unperturbed by the occurrence, resuscitation attempts are rarely commenced (if they are appropriate) and there are no single rooms for dying patients so the family can have peace. Screens are pulled around the bed after the incident but there are no candles or no Chaplin. One of the more humbling aspects of the death is that as the body is being moved to the mortuary all of the bed-siders for the other patients accompany the family there. The women cry and wail as the body passes.
As a doctor there are selfish aspects to death also. Recently whilst compiling mortality statistics for the past two months as I was terrified it would look awful but allowed myself be a little pleased when the ‘mortality rate’ was in fact similar to previous months. Some deaths seem to affect us more than others. Two types of patient tend to die here. The first presents extremely ill and passes away in the first 48 hours, these deaths tend not to affect us much. We didn’t get to know the patient ‘they presented too late there was nothing we could do’
The second presents with complex medical problems is in the hospital for a few days, we get to know them and their story recognise their relatives on the ward round. What limited investigations there are available are done in an effort to find out exactly what is wrong, various treatments are tried, books are consulted at night and thoughts turned over in your head. When they die there is more a sense of personal loss as well as failure. Then there is the frustration ‘if only I could have done this test, consulted that specialist, had the other medication’.
Overall the sad fact is that life expectancy at birth in this country is under 40 years. Several things will need to happen for this to change. Antenatal and perinatal care in the community will have to improve to decrease perinatal mortality. Immunisation programmes will have to be expanded to cover disease such as pneumococcus. There will have to be greater awareness of malaria prevention, safe drinking water and the dangers posed by diarrhoeal disease. The HIV infection rate will have to be decreased through mass testing and education. Health care staff numbers will have to be increased and levels of training vastly improved.
All of this will take money and political leadership, neither of which are in abundance in Zambia at the present.
Sunday, August 29, 2010
Monday, August 23, 2010
And on the seventh day
My Bradt guide to Zambia tells me there are an estimated 200 Christian churches in Zambia. Looking around the Katete area I see signs for Burning Bush Church, Jehovah’s Witness, a few different Catholic churches, the Anglican Church at the hospital as well as many others. Overall there is no shortage of places to worship on a Sunday if you are so inclined. Having associated the Jehovah’s witnesses mostly with Americans coming to your door with leaflets trying to convert you, I was surprised to see how big a presence that church has in this area from both the number of patients in the hospital who are members to numerous signs for various ‘Kingdom Halls’.
Frequently in the hospital the issue surrounding blood transfusion arises particularly regarding children who have anaemia secondary to malaria where the parents refuse consent to life saving blood transfusion because the are Jehovah’s witnesses. Thankfully many do seem to change their mind after a reasonable discussion outlining the facts, the absolute necessity for transfusion and the absence of an alternative. Keen as I am to experience as much of Zambian life as I can here I decided to take myself along to a gathering of Jehovah’s witnesses.
A school student tends to my small garden and after visiting his house and family who are all extremely welcoming and generous I discover they are Jehovah’s witnesses. They invite me along to a local convention. On the appointed day I meet my gardener and his dad and we head off. Just a couple of kilometres from the hospital we turn off the tar and drive for another four or five kilometres. We arrive at an immaculate little village with a nice school in the middle. A lot of others are arriving also, mostly on foot and by bicycle, though there are a few other vehicles.
I am introduced to Mr Phiri one of the elders of the congregation. We enter a large enclosure where several thousand others are already assembling. When I ask is this convention for all the eastern province he explains this is for the Katete area only. A couple of weeks earlier I had been to the Catholic service at Katete Stores so I am keen to compare the two. Whilst in the Catholic Church there were a few hundred I later learn there are eight thousand here. Proceedings start pretty much bang on eight thirty another big difference from the Catholic service which like most things in Zambia started considerably later than advertised.
There are several people on a stage with microphones and some speakers around the enclosure, everything is in the local language Chichewa. Mr Phiri gives me an English Bible and some sheets in English out-lining what is going on. There are five or six ten minute talks on different themes such as ‘Jehovah’s generosity’ or his loyalty or his consideration, it all seems pretty reasonable, there is much flicking through the bible from one snippet to another to explain these themes.
There is very little music and singing unlike the Catholic service which had a fantastic array of musicians with lively singing and people dancing in the church. What little singing there is some dull hymns to a tape recording of some drab piano music. It all seems very un-Zambian. Mr Phiri explains that all Jehovah’s teachings are the same the world over. True enough I see looking at my sheets that they are printed in Zambia but produced by the Watch Tower Bible and Trust society of Pennsylvania.
After the talks on the virtues of following Jehovah which all seem very reasonable we move on to the keynote speech. Here things loose the plot a completely. Following my English leaflet I see the address goes from dismissing the theory of evolution ‘how can we be descended from apes and still run away from them when we see them in the bush’.
I then learn that from a passage in Paul’s letter to the Romans the Jehovah’s witnesses foresaw the defeat of Nazi Germany in World War two. Indeed Himmler the head of the SS apparently once bragged that the Jehovah’s witnesses would capitulate but had no answer to the in the last days of the regimen before poisoning himself. I wonder how the average Zambian can identify with any of this. The address moves on to more rational issues that the seven million members worldwide are all apostles spreading the word ‘this is indeed the only organisation that God is using to help draw people to him’.
Leafing through the brochure I have I also see an article explaining that ‘we simply can not socialise with non-believers and hope to suffer no ill consequences.’ Bang on time at 11.20 the interval (and my cue to leave) arrives and Mr Phiri asks me for his thoughts. I first if all thank him for the kindness and generosity shown to me by him and the family that invited me which could not be equalled.
I explain that I found the experience very un-Zambian and struggle to understand the popularity of the Jehovah’s witnesses here. ‘We are an international organisation, anywhere you go will be the same’ he explains as we walk towards his vehicle a fairly new van with ‘Jehovah’s Witnesses Zambia’ printed on the side. He also explains that everyone who attends gets a bible which might cost 65 pen in the shop (about €11). He feels the main reason for their success is that all members must preach everyday so that others can hear their message ‘we are very serious with the preaching work.’
I am not so sure this can explain eight thousand people in an isolated African village. Perhaps there is an attraction to many in the dogmatic nature of the belief system. Perhaps there are other reasons. I ask Mr Phiri the burning question on the blood transfusion issue. He explains that it is written in Acts 15:28-29 and that there is not a total equality of blood. I protest that that surely all Gods children should be valued and not allowed to die when life saving treatment in the form of blood is available.
Mr Phiri calmly explains that ‘why do we bring our children to the hospital if we want them to die, you have other avenues like blood expanders’ I explain that we don’t in Katete and indeed these are no substitute for blood. I ask what will happen to the mother who will consent eventually to a blood transfusion for her child ‘we leave it with Jehovah and herself’.
Frequently in the hospital the issue surrounding blood transfusion arises particularly regarding children who have anaemia secondary to malaria where the parents refuse consent to life saving blood transfusion because the are Jehovah’s witnesses. Thankfully many do seem to change their mind after a reasonable discussion outlining the facts, the absolute necessity for transfusion and the absence of an alternative. Keen as I am to experience as much of Zambian life as I can here I decided to take myself along to a gathering of Jehovah’s witnesses.
A school student tends to my small garden and after visiting his house and family who are all extremely welcoming and generous I discover they are Jehovah’s witnesses. They invite me along to a local convention. On the appointed day I meet my gardener and his dad and we head off. Just a couple of kilometres from the hospital we turn off the tar and drive for another four or five kilometres. We arrive at an immaculate little village with a nice school in the middle. A lot of others are arriving also, mostly on foot and by bicycle, though there are a few other vehicles.
I am introduced to Mr Phiri one of the elders of the congregation. We enter a large enclosure where several thousand others are already assembling. When I ask is this convention for all the eastern province he explains this is for the Katete area only. A couple of weeks earlier I had been to the Catholic service at Katete Stores so I am keen to compare the two. Whilst in the Catholic Church there were a few hundred I later learn there are eight thousand here. Proceedings start pretty much bang on eight thirty another big difference from the Catholic service which like most things in Zambia started considerably later than advertised.
There are several people on a stage with microphones and some speakers around the enclosure, everything is in the local language Chichewa. Mr Phiri gives me an English Bible and some sheets in English out-lining what is going on. There are five or six ten minute talks on different themes such as ‘Jehovah’s generosity’ or his loyalty or his consideration, it all seems pretty reasonable, there is much flicking through the bible from one snippet to another to explain these themes.
There is very little music and singing unlike the Catholic service which had a fantastic array of musicians with lively singing and people dancing in the church. What little singing there is some dull hymns to a tape recording of some drab piano music. It all seems very un-Zambian. Mr Phiri explains that all Jehovah’s teachings are the same the world over. True enough I see looking at my sheets that they are printed in Zambia but produced by the Watch Tower Bible and Trust society of Pennsylvania.
After the talks on the virtues of following Jehovah which all seem very reasonable we move on to the keynote speech. Here things loose the plot a completely. Following my English leaflet I see the address goes from dismissing the theory of evolution ‘how can we be descended from apes and still run away from them when we see them in the bush’.
I then learn that from a passage in Paul’s letter to the Romans the Jehovah’s witnesses foresaw the defeat of Nazi Germany in World War two. Indeed Himmler the head of the SS apparently once bragged that the Jehovah’s witnesses would capitulate but had no answer to the in the last days of the regimen before poisoning himself. I wonder how the average Zambian can identify with any of this. The address moves on to more rational issues that the seven million members worldwide are all apostles spreading the word ‘this is indeed the only organisation that God is using to help draw people to him’.
Leafing through the brochure I have I also see an article explaining that ‘we simply can not socialise with non-believers and hope to suffer no ill consequences.’ Bang on time at 11.20 the interval (and my cue to leave) arrives and Mr Phiri asks me for his thoughts. I first if all thank him for the kindness and generosity shown to me by him and the family that invited me which could not be equalled.
I explain that I found the experience very un-Zambian and struggle to understand the popularity of the Jehovah’s witnesses here. ‘We are an international organisation, anywhere you go will be the same’ he explains as we walk towards his vehicle a fairly new van with ‘Jehovah’s Witnesses Zambia’ printed on the side. He also explains that everyone who attends gets a bible which might cost 65 pen in the shop (about €11). He feels the main reason for their success is that all members must preach everyday so that others can hear their message ‘we are very serious with the preaching work.’
I am not so sure this can explain eight thousand people in an isolated African village. Perhaps there is an attraction to many in the dogmatic nature of the belief system. Perhaps there are other reasons. I ask Mr Phiri the burning question on the blood transfusion issue. He explains that it is written in Acts 15:28-29 and that there is not a total equality of blood. I protest that that surely all Gods children should be valued and not allowed to die when life saving treatment in the form of blood is available.
Mr Phiri calmly explains that ‘why do we bring our children to the hospital if we want them to die, you have other avenues like blood expanders’ I explain that we don’t in Katete and indeed these are no substitute for blood. I ask what will happen to the mother who will consent eventually to a blood transfusion for her child ‘we leave it with Jehovah and herself’.
Saturday, August 7, 2010
Bwelani
I spend my mornings doing a ward round on St Augustine’s the male medical ward. There can be anything from twenty to forty patients to be seen there many with complex medical problems. In the afternoon I go to St Luke’s, our outpatient department. This is where patients have their first contact with the hospital. The HIV clinic is run from here as are the specialist Surgery and Gynaecology clinics. Room 15 is where the doctors from the medical department work.
I feel more at home here, its more like General Practice what I am used to, mixed in with a good bit of A&E and a general medical outpatients. Patients seen in room 15 are a mix of those for review post discharge, reviews of chronic illnesses such as asthma, high blood pressure and diabetes as well as those first presenting be it with chest pain, fractures, miscarriage, anxiety or to have a police report filled.
I sit at a desk like at home and see patient after patient. Bwelani (l is pronounced r) means come ahead (it’s the closest I know to next). One afternoon I see a 50 year old man presenting for admission for chemotherapy for Kaposi’s sarcoma. Bwelani – a 29 year old lady with an ectopic kidney and hypertension for review. Bwelani – a 78 year old man complaining of chest pain who has chronic obstructive airways disease.
Bwelani – a 63 year old man who has TB symptoms, sputums are negative, X-ray looks suggestive, start TB treatment. Bwelani – a 30 year old man with an acute exacerbation of asthma. Bwelani – a 20 year old student who has malaria. Bwelani – a 30 year old man new diagnosis Hepatitis B positive.
Bwelani – a 38 year old man new diagnosis of HIV positive, symptoms suggestive of TB, quite unwell and admit to the ward. Bwelani – a 24 year old lady with congestive cardiac failure secondary to rheumatic heart disease for review. Bwelani – a 7 year old girl with cough fever and constipation, admit to paediatrics (transpires has ileus secondary to pneumonia). Bwelani – a 69 year old lady with anaemia probably secondary to peptic ulcer disease.
Bwelani – a 19 year old girl previous Caesarean section in Mozambique at term, send to ‘waiters’ via maternity (waiters is a house in the grounds where women who should deliver in hospital wait). Bwelani – a 55 year old HIV negative man with sputum positive pulmonary TB, start TB treatment.
Bwelani – a 46 year old man with type 2 diabetes for review. Bwelani – a 36 year old HIV positive lady with pulmonary TB for review. Bwelani – a 3 year old boy with malaria. The afternoon concludes and its back to the still rather unfamiliar territory of the evening round on the medical ward.
I feel more at home here, its more like General Practice what I am used to, mixed in with a good bit of A&E and a general medical outpatients. Patients seen in room 15 are a mix of those for review post discharge, reviews of chronic illnesses such as asthma, high blood pressure and diabetes as well as those first presenting be it with chest pain, fractures, miscarriage, anxiety or to have a police report filled.
I sit at a desk like at home and see patient after patient. Bwelani (l is pronounced r) means come ahead (it’s the closest I know to next). One afternoon I see a 50 year old man presenting for admission for chemotherapy for Kaposi’s sarcoma. Bwelani – a 29 year old lady with an ectopic kidney and hypertension for review. Bwelani – a 78 year old man complaining of chest pain who has chronic obstructive airways disease.
Bwelani – a 63 year old man who has TB symptoms, sputums are negative, X-ray looks suggestive, start TB treatment. Bwelani – a 30 year old man with an acute exacerbation of asthma. Bwelani – a 20 year old student who has malaria. Bwelani – a 30 year old man new diagnosis Hepatitis B positive.
Bwelani – a 38 year old man new diagnosis of HIV positive, symptoms suggestive of TB, quite unwell and admit to the ward. Bwelani – a 24 year old lady with congestive cardiac failure secondary to rheumatic heart disease for review. Bwelani – a 7 year old girl with cough fever and constipation, admit to paediatrics (transpires has ileus secondary to pneumonia). Bwelani – a 69 year old lady with anaemia probably secondary to peptic ulcer disease.
Bwelani – a 19 year old girl previous Caesarean section in Mozambique at term, send to ‘waiters’ via maternity (waiters is a house in the grounds where women who should deliver in hospital wait). Bwelani – a 55 year old HIV negative man with sputum positive pulmonary TB, start TB treatment.
Bwelani – a 46 year old man with type 2 diabetes for review. Bwelani – a 36 year old HIV positive lady with pulmonary TB for review. Bwelani – a 3 year old boy with malaria. The afternoon concludes and its back to the still rather unfamiliar territory of the evening round on the medical ward.
Monday, August 2, 2010
Mutu uwawa?
After seven weeks I feel I finally have some notion of medically (and linguistically) what is going on. I am beginning to recognise patterns of disease figure out a little easier who might have TB, meningitis or toxoplasmosis. In the past number of days I have seen a surge in cases of meningitis some meningococcal, one pneumococcal and some Cryptococcal. The later seems to have a particular pattern of symptoms.
Cryptococcal meningitis is caused by a yeast infection. It is almost unique to HIV positive patients with severely suppressed immune systems (although some HIV patients present for the first time with Cryptococcal meningitis). The patient will have a long history of headache and confusion. On arrival to the hospital they will be confused agitated and not compliant with examination. Diazepam, with relatives consent, is frequently needed so that lumbar puncture can be performed for diagnosis. During lumbar puncture the CSF (cerebro spinal fluid) comes out at high pressure but is clear not like the turbid CSF I have seen with the bacterial meningitides.
One of the satisfactory things about medicine here is the pureness of it. There are no CT scans, simply do the LP bring the CSF to the lab who will often examine it straight away preparing the slides just like we were thought in medical school. There is nothing high tech about it. The latest case of Cryptococcal meningitis on my ward is Felix. He presented much like the others with a chronic headache, confused and agitated. He has been on treatment for five days now. My ability of pattern recognition doesn’t yet extend to knowing if he will survive the illness or not. Some patients like the one I mentioned a few weeks ago with the really high pressure CSF do well, others don’t.
Every day Felix’s wife sits by his bedside and cares for him. Staffing levels here are much lower than what we are used to in the developed world. ‘Bedsiders’ like Margaret are relied upon to carry out much of the patient care. Since Felix was diagnosed HIV positive in March this year he has been sick and has been admitted four times. This has had a huge impact on the lives of Margaret and the rest of the family.
Felix previously had a business repairing dishes and pots. Since he has been sick the family have had no income and are surviving on some savings and the good will of relatives. In the six days since Felix has been admitted Margaret has been here caring for him and sleeping on the floor beside the bed. Their three children aged 8, 5 and 3 are currently staying with Margaret’s parents. The family’s home is about 60km from the hospital.
During our conversation Margaret gets up to bring the bed pan to her 36 year old husband and after he has finished carries it to the toilet. Margaret tells me she also wipes him after bowel movements, washes him and changes the bed clothes. She will also be given any oral medication he is on to administer.
The care people give to their loved ones who are ill always astonishes me everywhere I have worked. Be it the lady who cares for her husband who has MS or the man in his 60’s who goes to the nursing home every day to bring his wife, who has had a stroke is immobile and PEG fed, out for a few hours. That is not to mention the countless others I have met caring for parents, siblings and children who are ill. Here in Zambia it is just the same.
Margaret has also tested positive for HIV but has not been ill like her husband. She is taking Anti Retroviral Drugs (ARVs). I ask her have the children been tested ‘not yet but it is important specially the little one’. Margaret tells me about how her and Felix first met. She was working in a shop at that time and knew his sister who informed her that her brother was looking for a wife to marry. They knew each other for three years before they married nut didn’t see much of each other at that time as he was living and working in the copper belt.
She says she doesn’t know why she and Felix have got HIV but she does know how it is spread. ‘It has been difficult for us to accept but emotionally we are there for each other.’ I take the opportunity to again explain to Margaret that Felix is seriously ill and may not survive this illness ‘I think Felix is going to get better, without him it would be difficult for me and my people to take care of the children’.
Through the ARV programme Margaret has learned a lot about HIV and its transmission. She feels that availability of ARVs is really important and that people should adhere to condom usage and not exchange instruments like razor blades or needles. She is a member of the Jehovah’s Witness Church but doesn’t feel this influences her views on healthcare beyond her objection to blood transfusions. She explains that in the future she would like to be able to educate all the children and build for the family a better house with a corrugated iron roof.
I am struck by her care and devotion to her husband. Margaret has one question ‘now that I am taking ARVs am I going to have enough life up until the time my children grow older?’
Cryptococcal meningitis is caused by a yeast infection. It is almost unique to HIV positive patients with severely suppressed immune systems (although some HIV patients present for the first time with Cryptococcal meningitis). The patient will have a long history of headache and confusion. On arrival to the hospital they will be confused agitated and not compliant with examination. Diazepam, with relatives consent, is frequently needed so that lumbar puncture can be performed for diagnosis. During lumbar puncture the CSF (cerebro spinal fluid) comes out at high pressure but is clear not like the turbid CSF I have seen with the bacterial meningitides.
One of the satisfactory things about medicine here is the pureness of it. There are no CT scans, simply do the LP bring the CSF to the lab who will often examine it straight away preparing the slides just like we were thought in medical school. There is nothing high tech about it. The latest case of Cryptococcal meningitis on my ward is Felix. He presented much like the others with a chronic headache, confused and agitated. He has been on treatment for five days now. My ability of pattern recognition doesn’t yet extend to knowing if he will survive the illness or not. Some patients like the one I mentioned a few weeks ago with the really high pressure CSF do well, others don’t.
Every day Felix’s wife sits by his bedside and cares for him. Staffing levels here are much lower than what we are used to in the developed world. ‘Bedsiders’ like Margaret are relied upon to carry out much of the patient care. Since Felix was diagnosed HIV positive in March this year he has been sick and has been admitted four times. This has had a huge impact on the lives of Margaret and the rest of the family.
Felix previously had a business repairing dishes and pots. Since he has been sick the family have had no income and are surviving on some savings and the good will of relatives. In the six days since Felix has been admitted Margaret has been here caring for him and sleeping on the floor beside the bed. Their three children aged 8, 5 and 3 are currently staying with Margaret’s parents. The family’s home is about 60km from the hospital.
During our conversation Margaret gets up to bring the bed pan to her 36 year old husband and after he has finished carries it to the toilet. Margaret tells me she also wipes him after bowel movements, washes him and changes the bed clothes. She will also be given any oral medication he is on to administer.
The care people give to their loved ones who are ill always astonishes me everywhere I have worked. Be it the lady who cares for her husband who has MS or the man in his 60’s who goes to the nursing home every day to bring his wife, who has had a stroke is immobile and PEG fed, out for a few hours. That is not to mention the countless others I have met caring for parents, siblings and children who are ill. Here in Zambia it is just the same.
Margaret has also tested positive for HIV but has not been ill like her husband. She is taking Anti Retroviral Drugs (ARVs). I ask her have the children been tested ‘not yet but it is important specially the little one’. Margaret tells me about how her and Felix first met. She was working in a shop at that time and knew his sister who informed her that her brother was looking for a wife to marry. They knew each other for three years before they married nut didn’t see much of each other at that time as he was living and working in the copper belt.
She says she doesn’t know why she and Felix have got HIV but she does know how it is spread. ‘It has been difficult for us to accept but emotionally we are there for each other.’ I take the opportunity to again explain to Margaret that Felix is seriously ill and may not survive this illness ‘I think Felix is going to get better, without him it would be difficult for me and my people to take care of the children’.
Through the ARV programme Margaret has learned a lot about HIV and its transmission. She feels that availability of ARVs is really important and that people should adhere to condom usage and not exchange instruments like razor blades or needles. She is a member of the Jehovah’s Witness Church but doesn’t feel this influences her views on healthcare beyond her objection to blood transfusions. She explains that in the future she would like to be able to educate all the children and build for the family a better house with a corrugated iron roof.
I am struck by her care and devotion to her husband. Margaret has one question ‘now that I am taking ARVs am I going to have enough life up until the time my children grow older?’
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