Food Scarcity and HIV in Uganda

The New York Times published an article today on Food Scarcity and HIV in Uganda. It's actually more of an opinion piece/narrative than a true news story. The author is a grad student in Public Health who is researching whether food scarcity and transport costs affect health outcomes in HIV patients. Duh!

As obvious as the answer to this question is to Mr Tuller or to me, I agree with him that it is important to study and publish the results. Otherwise Aid money will not help pay for food in patients who do not have enough to eat, much less for transport costs. How can we afford hundreds of dollars per patient per year for ARVs, but not a few dollars per month to help cover food costs?

Our program in Busia does not help patients with food costs and does not pay for transport to clinic. Most of our patients do not seem to be hungry, but I would say the majority of them have trouble scraping together enough money to get to clinic for scheduled visits. They often request less frequent appointments. This puts us in a difficult position; we would like to see new ARV starters weekly, rather than monthly, but often the patients cannot afford to get to clinic even once per month. On the other hand, the Kenyan Ministry of Health does not cover the full cost of medicines dispensed by public hospitals, much less the cost of food or transport. Some people would argue that Aid organizations should not cover costs for medicines, services, food and transport because such programs are not sustainable once the aid dries up. Complicated issues come up when you are dealing with poverty and chronic care. I think this is why MSF prefers to stick to natural disasters or conflict situations. It's less complicated when you can just come in during an emergency, help patch things up, then leave.

Lucy

is my new colleague and housemate. She is a nurse from London who has been with MSF on and off for the last seven years: Congo, South Africa, and somewhere else I can’t recall. I can’t help but contrast Lucy to the nurses at my old job in NYC who always seemed to be out on break. She is bright and hard-working (shown discussing PMTCT with Gabriella at left above). She uses funny expressions like "bips and bops," as in: "I'm going round to the office to collect the bips and bops I've left there." I think it means odds and ends.

Lucy knows more about tropical medicine and HIV than most of the doctors I’ve met in academic medicine. It makes me happy to think about the HIV negative babies who might have been born positive if Lucy had not been in charge of the Prevention of Mother to Clild Transmission program (PMTCT).

Top 10 Humanitarian Crises of 2007

I always love year end "Best Of.." lists, especially Jenny Davidson's annual best books list, and Brooklynvegan's collection of links to year's best indie rock albums. On the not-quite-so-lighthearted-side, MSF-USA publishes an annual top 10 most underreported Humanitarian Crises list.
The "top ten slideshow" is also worth a look. The picture of a the mother in blue from the Central African Republic is particularly electric.

Ebola

There is an Ebola Outbreak in Uganda. WHO reports that there have been 93 cases since early December, with 22 deaths so far. MSF sent teams from Barcelona and Switzerland to help with infection control. Kenya set up a tent at the border--just 3 km from our home-- to screen people entering the country from Uganda. We were called by a public health officer last week and rushed over, but it was a false alarm. I think I was the only disappointed member of the team. A case of Ebola! Now that would toot my horn.

Ebola is one of the filoviruses. It's clinical syndrome was detailed in The Hot Zone, a popular press description of the Ebola outbreak in monkeys in Virgina in 1989. I've read a few medical textbook descriptions of Ebola haemorrhagic fever which do not sound anywhere near as dramatic as the monkeys in the Hot Zone, who bled from every hole, crack, and crevice. Apparently the true clincal picture is much more akin to garden-variety septic shock, perhaps with a few scattered hematoma or petecaie thrown in. This leads me to wonder how a clinician practicing in Congo or Uganda would ever suspect ebola in the first place. Surely you can't go crying ebola over every fever, sore throat, headache and hypotension that walks into your waiting room.

According to Manson's Tropical Diseases, there have only been 20 or so Ebola outbreaks since the virus was first characterized in 1976. Manson says that primates probably are not the natural reservoir for filoviruses because they always get sick after infection, just like humans. A true natural host would have "latent infection," which means that the animal could harbor the virus without getting sick. There have been innoculation studies in bats that show asymptomatic viremia, which might indicate that bats are natural hosts. I guess I will stay away from bat infested caves if I ever get up to Uganda again.

Happy Hanukkah Hoboken

If I were in the States right now, I would be celebrating Hanukkah the way I usually do--front row center at Maxwell's in Hoboken for the eight annual YLT Hanukkah shows. Celebrating as the only Jew west of Kisumu just doesn't feel the same...

World AIDS Day 2007

Last year I posted a link to this picture on World AIDS Day. This year I thought I would post the actual picture. I don't exactly have permission to post this image, but I hope that Partners in Health (PIH) would not be mad, because I always use it to help patients in the spirit of PIH's treatment model of free health care for the world's neediest patients. We actually have posters on the walls of our clinic in Busia with this same picture along with explanations in Swahili of the benefits of ARVs for patients with AIDS.

The picture is of a Haitian man with HIV and TB who was (and presumably still is) a patient in the Partners in Health clinic in central Haiti. The left is a "before" image, when he was sick with HIV and TB. The right side is the "after" image, taken just six months later, after he was treated for TB and started on antiretrovirals (ARVs). I generally show this picture to patients before starting them on ARVS. I think it expresses the power of ARV treatment better than any speech I could come up with.