November 16, 2007

The Obvious Reality

I realize that I have not written much about HIV/AIDS yet. The virus is a/the fundamental force shaping life in many contemporary sub-Saharan countries, including South Africa, and I imagine it is the first thing many people think about when they hear the word “Africa.” Perhaps because it is so central to my work, it has been hard to tell any individual stories so here are some loosely-related thoughts on the issue.

People with HIV are certainly a part of my daily routine. There are many people in Itipini with the virus and their medical records are marked in such a way that it is obvious to me as soon as I look at the record that they are “positive,” as the preferred nomenclature has it. (A common question is, “What’s her status?” and regardless of the context people seem to know that the question refers to HIV.) What was initially notable for me was that many of the people whose records said they had HIV looked perfectly healthy to me and nothing at all like the pictures of emaciated and dying mothers and children you occasionally see when the western media does a feature on Africa. I am now in the habit of checking to see when a patient was first diagnosed and many have been living with HIV for four or five years or longer and still look quite vibrant to me. In medical terms, they are non-symptomatic and they aren’t even taking anti-retroviral (ARV) drugs like many non-symptomatic patients in the western world are. So for my first few weeks in Itipini, I started cultivating the foolish notion that this whole HIV thing was overblown.

My eyes are opening a bit wider each day, though, as we have been having a bad run of HIV-related illnesses lately. Patients are helped in by friends, carried in on stretchers, and in one case brought in by wheelbarrow, because they are so weak they can barely move. Some of these are the same people who I had initially thought were quite healthy-looking. It is stunning how fast one’s health can change. Sometimes I take these people to the hospital and it can be a bit unsettling to drive with a passenger who is so obviously suffering and to be able to do so little.

In South Africa, if you can’t afford ARVs the government will pay for them when your CD4 count (a measure of your white blood cells, I think) goes below 200, which is clinical AIDS. (A healthy person’s CD4 count is between 1000 and 2000, I think.) But there are a lot of obstacles to getting on ARVs, not all of which I pretend to understand. We can’t distribute ARVs at our clinic so they have to go to another government clinic that is about 20 minute walk away, a tough slog for someone whose CD4 count is below 200. The clinic keeps close count of your pills to make sure you are taking them all; if you lose a couple, you can be taken off ARVs. One of our patients had a CD4 count in the 160s in March. He tried to get on ARVs then but for one reason or another has not yet. He returned a CD4 count of 17 the other day, which is in the I-can’t-believe-you’re-still-alive territory. When he went to the clinic to see about getting on ARVs, they told him to come back next week. I hope he’s still alive then.

(To answer a common question, I don’t know what the ARV cocktail in use here is. I know it’s not the most up-to-date one in use in the U.S. but it’s also not AZT.)

When I was in Cape Town the other weekend, I happened to see an excellent production of the musical “Rent.” When I first saw the movie version a few years ago, my favourite song was the one sung by the members of an HIV support group, “Will I?” The lyrics are simple, “Will I lose my dignity? Will someone care? Will I wake tomorrow from this nightmare?” When I saw the show this time, I was overwhelmed by how the song spoke to my current work. I might not be able to snap my fingers and make these people better but I can do my part to ensure someone does care about how they are doing and that they will suffer with as much dignity as possible. How do you have dignity when you are reduced to being transported in a wheelbarrow?