On Tuberculosis and Bureaucracy

I am living a Tuberculosis nightmare. I get agitated when I think about it. I wish I had a sedative to calm my nerves as I write this.

The background: HIV and TB are a deadly combination. Unfortunately, they are also both common diseases. One-third (1/3) of the world´s population has been exposed to tuberculosis and is walking around with latent disease.

Most HIV-negative people do not get sick with active TB after they have been exposed. A healthy immune system usually controls the TB mycobacterium. Nevertheless, a few scattered mycobacteria hide away, alive and well, even in the healthiest of hosts. This is called latent disease. Should the host become immunosuppresed, the hidden mycobacteria are more likely to "reactivate"--multiply out of control and blossom into an active TB infection.

HIV positive people who have been exposed to TB are 100 times more likely to get sick with active disease than non-HIV patients. Not only does HIV make TB worse, but TB makes HIV worse. HIV patients with active TB have higher HIV viral loads, and their CD4 counts fall faster than patients without TB. Many patients with HIV and TB coinfection die. In fact, tuberculosis is the leading cause of death in HIV positive patients worldwide-- most certainly in places like Puerto Barrios Guatemala.

Doctors can usually diagnose TB in HIV-negative patients by ordering a sputum smear (pic at right). (1) Cough up glob of phlegm. (2) Smear phlegm onto microscope slide. (3) Throw on a few drops of dye. (4) look at slide under microscope. If pink "acid fast bacilli" are visible, the patient is deemed "AFB positive," and treated for active tuberculosis.

Unfortunately, smears are not a good way to diagnose TB in HIV positive patients. About 50% of HIV patients with active TB are "smear negative," which means that no organisms are seen under the microscope, even when the patient is swarming with them. The best way to diagnose TB in smear negative HIV patients is to send phlegm or other body fluid-- blood, cerebral spinal fluid, or urine-- for culture. Or, if you want to spend even more money, you can send the sample for a fancy DNA amplification test called PCR. Unfortunately, many "resource-constrained" (aka poor) places cannot afford to do TB cultures, much less PCR.

Public health authoçrities like the World Health Organization and the CDC have woken-up to the TB/HIV coinfection emergency. They also seem to have realized that poor countries cannot always send cultures, and therefore have trouble diagnosing smear negative patients. WHO recently published guidelines for diagnosing and treating smear-negative coinfected patients in resource constrained settings. These guidelines urge doctors to treat smear negative patients even in the absence of a confirmatory culture. When HIV positive patients have signs and symptoms of TB ("high- suspicion" patients), the guidelines recommend treatment, even if smears are negative and no cultures are available.

Unfortunately, the Guatemalan Ministry of Tuberculosis has not read the WHO guidelines. Or maybe they think Guatemalan coinfected patients are different from coinfected patients in other countries around the globe. Who knows what they are thinking? All I know is that many of our smear-negative patients cannot get treatment.

You can walk into almost any pharmacy in Guatemala and buy antibiotics, sedatives, narcotics, proton pump inhibitors, mega-dose injectable vitamin B12, and kill-your-kidney injectable NSAIDS without a prescription. But you cannot buy INH, Rifampin, or Ethambutol, the drugs used to treat TB. these drugs are only available from the Centros de Salud (primary health care centers). Unfortunately, when we send our smear-negative patients to the Centros de Salud for treatment, they are often told that they cannot get treatment unless they have a positive smear or culture. Our letters and phone calls are not much help.

What happens to our patients? An example: A 42 year old man with HIV, previously doing well on antiretroviral therapy came to the clinic with cough for a couple of weeks. We gave him antibiotics, an "empiric" treatment for bacterial pneumonia, and sent three sputum smears for AFB. All the smears came back negative. He was no better in a couple of weeks. He was losing weight and he looked weak and tired. We sent him for a chest X-ray (shown above right). It does not take a pulmonologist or radiologist to see that the left side is different than the right side. Hummm.... HIV positive, cough, weight loss, night sweats, not better with antibiotics.... could it be... TB??? But when we sent the patient to the health center with a letter and a copy of his X-ray, he was told he could not get TB treatment because his smear was negative. The health center employee would need to write a letter to the central office in Guatemala. If they approve empiric treatment in one of their upcoming meetings, the patient might be approved for empiric treatment. In the meantime, he would have to wait. It could take weeks, even months for the central office to get to his case. I blew my stack when he came back and told me the story. My temper tantrums do not help.

Until Guatemala changes it´s practice for management of smear negative TB in HIV positive patients, our patients are in serious trouble. In fact, we are all in serious trouble. I can only hold my breath for so long, before I breathe in one too many AFBs.

Google.earth

This has nothing to do with Guatemala or AIDS or medicine.

Have you seen google.earth? It an amazing computer program. When you open it, you see a picture of earth on the cmputer screen. By clicking the mouse, you descend to earth from space, down to whichever continent you choose. As you get closer, you can navigate to the location of your choice, right down to individual buildings and landmarks. I went from space to 102nd st., between WEA and Riverside, in about 20 seconds! They finally took down the scaffolding outside my old building, I see.

Conrado is in a China phase. He is sick of Spain.

Cell #2 Leadership Visits Project Barrios

Silvia and Paco visited Puerto Barrios last week. Silvia is the TESACO (MSF lingo for Barcelona high-honcho) for MSF-Espana, celula #2. She started as a lowly field doctor, just like me. On subsequent missions she moved up in responsibility, from field coordinator, to medical coordinator, to technical advisor for cell # 2.

Cell # 2 runs MSF-Espana missions in Guatemala, Ecuador, Congo, India, Bolivia, and Columbia. Paco is in charge of finances for the cell. Cell # 2, I should note, is the shining star of MSF-Espana. Once you work in cell # 2, it´s hard to go anywhere else. And I landed here on my first mission!

We met with Silvia, Paco, and Regina, the Guatemala country coordinator, last week to discuss the work we need to do before the project closes next year. Pic above left shows Silvia (in white sweater) working on computer in between Regina (in yellow) and Nuria (in black).

Visitors from the Capitol or Barcelona headquarters stay in our house when they visit the field. Pic at right shows our team hanging out with Regina (in pink), Paco (in black shirt, second from left) and Silvia (on sofa in white). Notable difference from my old job--I would not want to hang out with my boss´s boss´s boss in NYC, much less see him/her on my way to the bathroom in the morning.

Whatever Happened to the Patient?

Lawrence Altman had an article yesterday in www.nytimes.com on the sad evolution of grand rounds. I feel light years away from Grand Rounds here in remote Guatemala, but this article dug up some buried frustration with academic medicine leftover from my days in Northern Manhattan.

Altman explains that patients used to be the centerpiece of grand rounds. A junior clinician presented the patient´s case to a master clinician. The master clinician taught the audience how to talk to the patient, examine the patient, and synthesize information to formulate a diagnosis.

These days Grand Rounds are about anything but the patient: basic science, clinical research, epidemiology, ethics, imaging, new and improved lab tests, health policy, financing, "the IIbIIIa Receptor, Yet Another Update," etc. etc.

Altman could have argued that Grand Rounds is just another example of the loss of patient-centered medicine. Somehow patients have virtually disappeared from the academic medical center. There are groins in the cath lab and liver biopsies in the pathology fridge, but an entire patient is nowhere to be found. Maybe they got lost amongst the grant applications, in the labs, or under the piles of insurance paperwork.

¡Ojo!

On the living room floor....

World AIDS Day

In honor of World AIDS Day, December 1st, I refer you to the following link. It is a New England Journal of Medicine editorial from earlier this year written by Dr. Jim Kim, who is a professor at Harvard, a founder of the NGO Partners in Health, and en ex-employee of WHO.

If the article bores you, at least glance at the picture of a Haitian patient before and after treatment with antiretroviral medicine. Amazing.

Spanglish

I don´t speak English anymore. I speak a rare form of Spanglish. It is mostly Spanish, with a few words of English thrown in. Sometimes I get sick of Spanish, so I speak English, with a few words of Spanish thrown in. Both forms of Spanglish have miserable grammar, a mix of spanish and english constructions with dangling modifiers or gerunds and whatnot. I´ll tell you a story in Spanglish (the mostly English form):

Dolors, my boss here in Guatemala, has a sister. The hermana is a native a Catalunya, which is a country near Spain. The sister teaches English to gente in Spain who want to learn English.
Lola gave the sister the address of this sitio de Internet, so she could look at pictures of Guatemala etc. The sister told Lola that I tengo terrible English grammar. What a diss!

I saw a movie on TV about a futuristic society. All the people are of mixed race. They ripped off my Nell-brand Spangish for their script. All the characters habla a form of Spanglish remarkably similar to my own. I am going to my casa now. More Spanglish, mixed with some Medspeak to come...