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?’
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