Sunday, September 28, 2008


Corruption in Africa is widespread. So widespread in fact that most us aren't even suprised by it anymore. Occasionally, however, someone comes along and takes corruption to a whole new shocking level.

Just as common as corruption around these parts is the desire for a DG or disability grant. It is highly sought after. Scoring a disability grant is almost like scoring a jackpot to alot of patients around here. It's a strange phenomenon. Even better than getting a DG for a serious illness though, is getting one for no good reason at all.

What I am about to say is absolutely true.

A group of staff members at a community clinic were caught trying to abuse the social welfare system. In South Africa, the government grants DG's to HIV patients with CD4 counts less than 200. So what these people did was intercept the blood specimens of HIV positive patients who looked very ill and send the blood away for a CD4 count under their own names. In this way, they had a legitimate record of a very low CD4 count which qualified them for a DG.

Fortunately though, the actual application for a DG has to be filled in by a doctor (usually one who does nothing else but that) and when one of these people approached one, he was suspicious of a very healthy looking person supposedly having such a low CD4 count. In this way, this person and eventually all of them were caught out. They even received disciplinary action. Now that's something that's rare in Africa.

Friday, September 12, 2008

Too late

One of the most difficult things in medicine is accepting that there was nothing more that could have been done.

One case that affected me quite badly was that of a young pregnant woman with TB .

When she came in she was already 7 months pregnant and had been on TB treatment for a few months. She was in a bad way. She was wasted and malnourished, had oral candidiasis and was short of breath. She tested HIV negative on rapid test. I didn't believe the results so I sent stat blood to the lab for an Elisa. It also came back negative.

In the meanwhile, she'd had a chest x-ray which should extensive infiltrates and lung damage - she barely had any normal lung left.

I made a tentative diagnosis of multi-drug resistant TB.

The baby was also not doing so well. There was very little amniotic fluid and although there was a heartbeat on ultrasound, there were no foetal movements.

The patient also complained of abdominal cramps and on abdominal exam she did seem to be having some mild contractions. On vaginal exam her cervix was very posterior and very difficult to assess.

I sent her to the state hospital with a diagnosis of probable multi-drug resistant TB, oligohydramnious and possible early labour.

She was reluctant to be admitted but her mother seemed to understand the gravity of the situation and talked her into it.

Next day, on enquiring after her at the state hospital, it seemed there was no record of her being in either the gynae or obstetric wards (the baby was viable, but the state hospital did not have adequate staff or resources so whether the baby was considered viable by them probably depended on whether they had a neonatal ICU bed. Nevertheless, she was apparently in neither ward.)

I remember thinking that she might have absconded, considering how reluctant she had been to be admitted. More likely though was that she was in fact in the ward but the hospital staff were just too lazy to look and claimed they had no patient by that name (very, very common in South Africa. In fact, if you enquire after a patient, it's the exception rather than the rule that anybody bothers to make any effort to help you).

About two months later, I saw her mother again on an unrelated issue. She told me that her daughter had been admitted to the hospital. She said that the baby had died in utero and that her daughter had then died a few days later.

I was devastated.

She had essentially died from a curable disease.

What had happened up to the point that she'd presented to me was uncertain. Whether the system had failed her, or she had been non-compliant, I don't know, but from the time that I saw her, it was already too late it seems.

Friday, September 5, 2008

Love and devotion

With HIV positive patients you get two types of families. Either the family abandons the patient altogether, or they are highly involved and do everything they can to ensure the patient gets help.

(Unfortunately, even with the latter type, patients who have been away from their families often only return to their families when it is too late and sometimes even refuse treatment even when the family members -usually their mothers - do everything they can - even forcing them to go to hospital etc.)

One day I saw a very elderly woman who tested HIV positive. She was about 75 years old and demented. She also had a previous stroke (found on examination, not history), was blind from cataracts, and was in
adult nappies (diapers) with a severe nappy (diaper) rash.

I couldn't help wondering why, with all these co-morbidities, she had been brought in to test for HIV. I was even more surprised that she had tested positive.

The only thing that could really be attributed to the HIV was that she also had a severe peripheral neuropathy. The dementia may also have been attributed to the HIV but AIDS Dementia is really a diagnosis of exclusion and I thought it was probably due to something else in her case considering her condition. According to her family member though, she had been quite functional before and had rapidly deteriorated in the last month or so. I felt that she was in a dismal condition, but in view of this, decided to do a work up.

The family member who accompanied this woman was her 20-something year old grandson. He had been taking care of her for a while. This was an exceptional case so I didn't expect him to fall into either family category frankly. In fact, I felt quite sorry for him: I thought his sick grandmother was probably quite a burden for this young man but that he had been caring for her out of duty and now needed some reprive.

I got the social worker involved. My plan was to admit her to hospice, treat her other problems symptomatically and do a work up for the dementia. Thereafter I planned to place her in a long term palliative care facility. I decided that if the dementia was due to AIDS Dementia Complex, I would start her on ARV's, otherwise I didn't think it would be practical or beneficial.

I asked the social worker to explain the situation to the grandson and then arrange placement. The grandson however was not happy with this plan. He did not want his grandmother to be placed in a palliative care home, he wanted to take care of her himself!

I was amazed. Here was a young, single male telling me he wanted to care for his sick elderly moribund grandmother.

As it turns out, this woman had only one child - a daughter. Her daughter in turn had 3 children. The youngest of these was the young man now accompanying his grandmother. His mother (the patient's daughter) and 2 siblings (the patient's other 2 grandchildren) had all passed away (I didn't ask what of but in our setting it's likely it was also due to HIV). This sick elderly woman was therefore the only family he had left.

I was so touched I nearly cried.

I had such sympathy for this young man, but more than that I was deeply impressed by his devotion to his grandmother.

It seems there really are selfless people out there willing to do whatever they can for the people they love.