Global TB crisis demands action

Tuberculosis (TB) remains one of the greatest threats to human health in the world. A neglected disease, it infects one third of the world’s population and is the second leading infectious killer, causing about 1.5 million deaths per year. Worldwide, MSF is treating more than 30,000 patients for tuberculosis, and advocating for research into improved treatment regimens.

Yet in many of the countries where Médecins Sans Frontières (MSF) works, much remains to be done to properly diagnose and treat TB. In Chad, I have seen patients treated five times, unsuccessfully, for pulmonary TB. In rural and isolated regions of the country such cases are common and investment in medical services is lacking.

TB is a complicated disease – it can be difficult to properly detect, and the treatment is often long and unpleasant. These problems are exacerbated in many places where MSF works, places where people struggle to access healthcare. TB patients can be discouraged by the harsh side effects of the drugs and stop treatment, or they may lose access to the medications they need.

As an emergency humanitarian organization, MSF is often stretched thin trying to treat complicated TB cases alongside other acute health needs. In Chad, we respond to epidemic diseases such as malaria, mass trauma incidents and spikes in malnutrition. Here and in other MSF missions, I have faced the difficulty of implementing TB programs alongside other seemingly endless priorities, constrained by limited human and material resources.

But we cannot ignore TB – if we do, the consequences for patients become even more severe. When the disease is treated incorrectly, the TB bacteria can develop resistance to the most commonly used drugs, making successful treatment much harder.

Raghu (L) on the ward in MSF's hospital in Am Timam © Kevin Hill/MSF

Treating TB in Chad

Last year, at the MSF hospital in Am Timan, eastern Chad, I treated a TB patient named David (not his real name) who endured a fever for more than two months. With the outside temperature over 40 degrees Celsius, he suffered terribly. While David suffered, I felt discouraged, fearful that he would die and hoping for an elusive breakthrough.

David, in his twenties, had a cough, chest pain and was emaciated. He weighed just 45 kilograms. Each day when we visited him on the TB ward, he gave us a tired smile and agreed to stay a little bit longer for treatment, despite the apparent lack of improvement in his health.

In my work with MSF, I have often found it a challenge to isolate highly infectious patients from their family and fellow patients. David came from a small village near Am Timan, and his mother kept watch over him during his hospitalization. For the sake of her own health, we implored David’s mother to stay outside of his room during his treatment, but she would not listen to us and kept by her son’s side.

David kept his few belongings – blankets and clothes – neatly folded and as clean as possible, washed by hand. Yet his ward was dirty, his bed frame rusted and there was dust everywhere. This was David’s home for the duration of his treatment.

David was treated for TB in 2008 but was diagnosed with the disease again in 2013. In Chad it’s not uncommon for patients to abandon our hospital despite close medical attention, detailed explanations and psychosocial support. Traditional medicine is common in this region and western medicine is not always accepted by villagers who have sought the help of local healers for generations.

From March to May of 2013, David was treated with the usual TB antibiotics. Despite the treatment, his symptoms persisted. David grew frustrated. Were it not for the time we took to explain our efforts to him, with the aid of local counselors, I fear he would have abandoned treatment and likely died.

In May, David was still testing positive for TB despite the two months of intensive treatment. He spent his days in the isolated TB ward with a towel draped over his shoulder and his prayer beads by his side.

Raghu and the MSF team discuss David's treatment © Kevin Hill/MSF

Raghu and the MSF team discuss David's treatment © Kevin Hill/MSF

New approaches to diagnosis and treatment

Traditionally, TB has been diagnosed by taking a sputum sample and directly observing the bacteria under a microscope. This method is time-consuming and unreliable but is the standard for MSF around the world. Many cases are missed, and drug resistance isn’t diagnosed at all.

Our medical team eventually suspected that David was probably infected with drug-resistant TB (DR-TB). Globally, MSF TB programs are seeing alarming numbers of patients with drug-resistant forms of the disease. Fewer than one in five people with DR-TB have access to care. In our region of Chad, patients with DR-TB wouldn’t have access to care without MSF.

For some time, MSF had been preparing to test and treat DR-TB in Chad. These efforts would prove essential for David’s survival. First was the deployment of a new TB testing technology called GeneXpert. The GeneXpert machine is the size of a desktop computer. It works by detecting the genetic structure of the TB bacteria, and also tests for resistance to the most important TB drug, rifampicin. GeneXpert delivers results in two hours, instead of the months required to send samples to Europe for advanced testing.

We now have the means to diagnose more DR-TB, put drug-resistant patients on treatment faster and stop prescribing ineffective medications to patients who need specialized drug regimens. We can also help expose the size of the global DR-TB epidemic. MSF currently has 26 field sites around the world that are using this new technology.

David was the first patient in Chad to benefit from GeneXpert. In June we tested him with the new system and discovered that he had high-grade resistance to rifampicin. By July, the government agreed that we could start treating David for DR-TB.

David then embarked on a new nine-month treatment program. The standard two-year regimen for treating DR-TB has many debilitating side effects, including loss of hearing, vomiting and psychosis. MSF has used this regimen in the past, and patients and their doctors found it difficult at best. The new treatment protocol significantly reduces the side effects and the number of painful daily injections. This increases the likelihood that patients like David will complete the treatment.

The new drug regimen we offered David is not only less harmful and more effective, but is also about a quarter of the price of the two-year treatment.

TB patient David finally tested negative in September 2013 © Kevin Hill

TB patient David finally tested negative in September 2013 © Kevin Hill/MSF

Enormous challenges

In September 2013, David finally tested negative, likely for the first time in six years. But curing DR-TB isn’t easy, and TB bacteria were detected again when David was tested in November. The field team suspected that David wasn’t taking his medications regularly, and made sure that a community health worker visited him every day to encourage him to stay on treatment. In December, David tested negative.

David is now back home in his village, where he faces stigmatization. Motorcycle taxi drivers are reluctant to give him rides for fear of being infected. MSF community health workers explain to the villagers that David is receiving treatment and that the risks of infection are low. Yet it’s uncertain whether the community will accept David.

David has monthly checkups at the MSF hospital, and daily support from community health workers. Thanks in part to his courage in persevering despite his suffering, he is on the way to being cured of TB.

There are enormous challenges to successfully diagnosing DR-TB in poor countries. MSF is doing what it can, but it isn’t nearly enough – our programs are only scratching the surface of a huge global health problem. Large-scale action is needed.

MSF has launched a DR-TB manifesto calling for universal access to diagnosis and treatment, better treatment regimens, and the funding to meet these goals. Please visit and sign the “Test Me, Treat Me” DR-TB manifesto.

Raghu

Thanks to Dr. Andreas Schoenfeld and Prosper Ndumuraro for contributing to this article.


Raghu is now back at home in Canada where he wrote this piece which first appeared in MSF Canada’s Dispatches magazine.

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To the Berlin headquarters

On Monday June 3rd I last wrote from Amtiman, Chad. Today is Friday June 7th and I am writing from Paris, France. I’m about to get on the plane for home in Toronto, Canada.

Amtiman now seems so far away from here in Europe. However, if I think of sand on the ground and heat on my skin, potholes in the dirt road, and a few pieces of garbage on the ground between the expat house and MSF office, I am taken back. Thinking of Amtiman is a powerful, spinning feeling. It’s a bit hard to write since I’m so tired right now. All I can mostly do is sleep and walk around in a bit of a daze. But let me try to write something.

MSF Chad

My tukul in Amtiman on my last day © Raghu Venugopal

 

On the way out, first the flight was from Amtiman to Abeche. Before Amtiman, the plane had first passed through Tissi and collected our MSF staff on their way out from this humanitarian emergency. They had stories of the difficulties in Tissi, serving the population who had fled in fear for their lives and who had little but what they could literally carry in their hands. As well, some staff were coming into Amtiman from the capital and getting off the plane to stay. On the tiny dusty airstrip we all said hello, goodbye, “bon courage” and thank you.

Papa Gadura, our Chadian head of the drivers, gave me a big hug. Luigi, from Italy, our project coordinator, came to the airstrip to say good-bye. Him and I had worked so closely together in this mission. It was really so incredible to work alongside Luigi and my medical coordinator, Cristina, from Spain on operational issues. This strategic work, alongside seeing many of the toughest patient cases encountered by the medical team, had really made my mission worth it. Ben, our logistician from Germany, was also there, since it is his job to manage the airstrip. I had given him my favorite shirt some months ago when he had said he liked it – what a wonderful man – I had always thought. And yet in minutes, the plane was in the air. It was over.

In the air, I thought about the last few months. Fatigue, exhaustion, satisfaction, and relief. I felt happy to have just survived. I felt just happy just to be alive. My biggest fear had been the heat, the job I had been given and the ill-deserved reputation of some of the local staff. All had turned out to be more or less fine. The heat – it was predictable – and was a struggle all the time, and I never really got used to it. The job I was given – well, I thought I had earned my keep and made some progress alongside the whole team. Lastly, our staff – had almost uniformly been lovely to work alongside. It had been hard on my girlfriend Maeve and I – but we grew stronger apart in some ways too – we decided to get married when I was in Chad. She was alone at home with her dog Daisy when I called from my tukul one night and asked her to marry me. I remember feeling a mix of nervousness and readiness as I paced in the confines of my tukul staring up at the thatched roof covered in dust and cobwebs. Even after Maeve said “yes”, I loved texting her many times “mm” (code for marry me) on my little Nokia cell phone that allowed a little link between us at all times.

On the flight out I sat beside Fabienne, from France. She has been a friend for many years. We had first met when she worked in human resources in the Toronto office of MSF and I served on the Board of Directors of MSF-Canada. Later she was my human resources coordinator in Goma, in eastern Congo. Staying with MSF-Holland these last four missions had meant seeing many old friends in far-flung places, and making new ones too. It is a good feeling. When we got to Abeche, we all spent the night at the MSF-Swiss compound. Those working in Tissi (Martine from Holland and Syed from India) went to the hospital where their sickest patients had been evacuated. They were thrilled to see their patients alive and so happy to see them. We sat in the thick, hot night air very pregnant with the expectant rain, which eventually fell in torrents. Martine, from the MSF-Holland emergency team, shared amazing stories from her many last missions – many of which had criss-crossed mine. She was on her way to Syria next. We all got updates from each other about friends. The mood was light.

I got up the next morning at 05:50. After a quick coffee we were in the air to the capital. In N’djamena I collected my precious passport and caught upon on email. I debriefed with a couple of colleagues, looking back at the lessons learned and way forward. I found a corner of a table and tried in vain to catch up on email. A huge bougainvillea amidst MSF generators and cars in our compound gave me more flowers to press and to give to Maeve. In the night we went to dinner at one of our favorite places – the Cote Jardin. I had just taken a shower but was drenched in sweat again. But the beer was cold at least. It was a good time.

The head of mission, Stefano, from Italy, was at his end of mission and was leaving along with me. We boarded the Air France plane at 11pm and were in the air. It was a good feeling but one of disbelief too. I could not sleep the entire flight and watched a movie instead. When I got to Berlin at 10am I went straight to the MSF-Germany office to debrief. There, again, I met many former colleagues and people who I knew by email and phone, but had never met in person. Christian, from Germany, an an operational manager, along with Adele, from the UK, a humanitarian affairs advisor – along with I – met first. Christian and I had done this before in 2010 after I had worked in the Central African Republic. Since that time I felt I had grown more experienced, more humble and a tad more wise. Catherine, from Canada, working in communications met with me next. Then I met David, from Spain, over logistics; Olivier, from France over human resources; and then two quick unplanned meetings with two people whose names I did not quite catch – but who manage our pools of nurses and midwives.

The Berlin office where our operations are based © Raghu Venugopal

 

I was wired on about five cups of coffee by the end of the day and had not slept enough in the past three days. But everyone in the office was friendly and welcoming and if felt good to share the experience from the field and hear about how Amtiman and Chad had been in the past. The time in Berlin was well spent.

Dr. Anja, from Germany who I had followed in both Congo and Chad, picked me up from the office. We’re about the same age and have about the same amount of experience in MSF. We sat in the warm German sun and reflected on the last period. She took me to a huge beergarden and we shared a mix of hopes and dreams, frustrations, and relief.

The next day I completed a few smaller meetings and then was asked to speak at the office staff meeting. A map of Chad was projected on the screen and I laid out our operations to the assembled staff from the human resources, finance and administration, fundraising, communications and operational departments. I talked about three patients to outline our operations to the headquarters. All three have been part of this blog. The first was a pregnant woman with triplets, then Ali, a young man with drug-resistant tuberculosis and lastly Mariam, a woman co-infected with both HIV and TB. I used this opportunity to bridge the field with the headquarters and share with our Berlin staff a sense of what makes our work in the field so special and what challenges our patients face. The staff asked friendly questions, and just when they started asking about the Tissi emergency, Stefano arrived from his debriefings in Amsterdam, and shed light on that situation.

It’s time go home. It was nice to debrief in Berlin but I’m longing for Canada. I’m going to see Maeve (and Daisy) very soon. The joy of no curfew, my own bed and the safety and security of Canada awaits. Ones rights and fortunes become crystal clear when you can come back home from the field. It is jarring for me every time. But Amtiman stays on my mind. Maybe I will return one day. I am ready if I am given the chance.

Farewell for now from the house-call….to Chad.

Raghu

Raghu Venugopal

Raghu

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Ins and outs in eastern Chad

The dry hot season is going out and the cooler rainy season is coming in. Heavy showers have begun to fall and it is a relief for everyone. The rains bring life to the land. Out of dirt springs green. Crops take root. Starvation will hopefully ease. With the rains here in eastern Chad have also come a range of different insects. Large grasshoppers, flying ants and beetles arrive in waves. At night a few seem to get into my bed and tickle me despite my careful tucking of my bednet around my mattress.

Patient care keeps on going all the time. It is the life-force of MSF. It keeps me most satisfied. Dr Carla asked me yesterday to co-examine with her a two-year-old boy with sickle cell anemia and a painful, swollen left arm. I examined the child as carefully with my iPhone in his mother’s hands playing U2’s “With or Without You”. U2 is a fine distraction for a child and I like it too. I was rewarded with no crying. A two-month old baby we saw also together was kicked in the head by a camel. A huge hematoma overlay a serious skull fracture. But the baby is breastfeeding and we’re hopeful for a good outcome. Another child had a severe cleft lip and palate. We’ll keep the baby’s name and contact information in a register in case another specialized surgical organization comes here soon who can repair the problem.

MSF Chad
Day in and day out – examining and performing ultrasonography of a complicated case at the request of the Amtiman medical team. Consent for photo and publication by the family obtained. © Raghu Venugopal

 

After seeing some patients with Carla, a maternity nurse then rushed over to ask for help for an 18 year old women in a semi-comatose state. She had recently delivered a child in her village that did not survive. The mother had convulsions in her village and an elevated blood pressure. An ultrasound of her abdomen was normal. So was her malaria test. We treated the young woman for malaria nonetheless, as well as meningitis and hypoglycemia. Despite ongoing care and close attention, she died yesterday – probably from seizures due to eclampsia, as well as possible bleeding in her brain. This is caused by untreated high blood pressure in pregnancy – a problem MSF screens for among hundreds of mothers each month. After I first examined this patient I knew her prognosis was grave. I found her brother, and sat down with him on two chairs threatening to fall apart. I explained we would do our best, but the likelihood of survival was limited. Death is around us. But, moreso we are surrounded by life and survival. Day-in and day-out, this is the reality of our work here in eastern Chad.

Malnutrition is a still a major priority. The hospital is full but under control. In the past few months, we have increased the number of doctors and nurses in the hospital to better manage the situation. MSF is furthermore making a substantial contribution to improve the Amtiman hospital physical structure itself. In addition to having already constructed a new intensive care and triage building, our American construction logistician Gardy and his team are building a new maternity building. This will mean women under our care no longer need to be hospitalized in a tent. A new pharmacy is being built by MSF at the same time. To improve the function of the older buildings, our logistical team led by Ben from Germany is currently rewiring the electrical system for the entire hospital. We’ve moved all our patients into tents during this rewiring process. Led by our Canadian water and sanitation engineer Diana, we are spraying the wards with a safe insecticide to prevent malaria. These changes will improve the district hospital’s function for years to come.

As is the case with MSF, the team is evolving and changing. There are always ins and outs. A large number of experienced MSFers have come in and out en route to the emergency intervention in Tissi – at the tri-border of Chad, Sudan and the Central African Republic. A few of our Chadian staff have gotten married and had children – requiring breaks from their usual jobs with us. Some of our Chadian staff have been integrated into the ranks of the Ministry of Health (which is a positive development), requiring us to hire more nurses. Expats are coming and leaving the Amtiman project as well. Eve our Canadian hospital nurse, has been replaced by Miet, from Belgium, now on her 9th mission. Ben, our German logistician is being replaced by Andreas, another German logistician. Louise, a pharmacist from Ireland has arrived on her first mission.

Ins and outs - the movement planning of expat staff in and out of Amtiman. © Raghu Venugopal

 

No replacement for my position as medical team leader has been found yet. That’s the way it is sometimes in MSF. There is a limited pool of qualified human resources. In this case, the team is flexible and covers for each other. Dr. Carla, a German doctor on her second mission, has agreed to cover my position on an interim basis until MSF can fully replace me. Each day lately, I share a little bit of my current job with Carla, despite her busy job as a hospital doctor. Her flexibility is appreciated by the team. Flexibility and adaptability are key principles in MSF work.

In support of our mission in Chad, MSF has recently deployed to us some welcome visitors. Dr. Krys, from London, UK is specialized in the care of HIV and TB patients. He works at MSF-UK’s Manson Unit, which sends HIV/TB experts around the world to work with MSF teams for a few weeks at a time. Krys has loads of field experience. Since is arrival, Dr. Guy from Congo, Krys and myself have rounded on patients and shared ideas with the rest of the team how we can improve the care of patients infected with HIV and TB.

MSF cannot exist without the generous donations from our supporters. For this reason, Julie and Kevin from MSF-Canada traveled to Amtiman this week to gather field testimony and conduct a donor accountability webinar. Eve and myself went live on-line this week, with the help of Kevin and Julie, to talk with our donors and supporters. It was wonderful to have two Canadian friends in the project. They brought a few treats to the team, especially some good old “Kraft dinner” (macaroni and cheese), which to my surprise went down well with all members of the team who hail from around the world. Kevin and Julie also brought some lovely English language books, which are a present to our national staff, many who wish to learn English.

In one week I am going home. My fiancé Maeve and I are getting married soon. We text, email, Skype and call each other as regularly as possible. The phone bill at the end of my mission will not be small, but every second of contact with her is worth it. She is a strong supporter of my mission and MSF. But the distance is not easy on either of us. I’m lucky to have found such a wonderful partner in life.

Ins and outs is the reality of MSF. The turnover of the team is actually healthy. New ideas and experiences enrich our work and the MSF social movement. It keeps us questioning our relevance, our quality of work and the value of our interventions. It makes MSF the strong organization that it has become, in service of Chadians.

Farewell for now from the house-call….to Chad.

 

Raghu

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Live webchat with Raghu, 2pm EDT

UPDATE: Watch Raghu and Eve’s webchat online

This afternoon (Wednesday 22nd May) Dr Raghu Venugopal and fellow Canadian aid worker nurse Eve Charbonneau will be taking part in a live webinar from Am Timan, Chad.

The focus of the web chat is MSF’s work on malnutrition and the impact your donations have on the lives of people in Chad.

Please tune in here at 2pm EDT; 7pm BST; 8pm CEST and login to ask Raghu and Eve questions about their work.

Thanks
Clare, MSF’s blogging coordinator.

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From base to boardroom to bedside

Wednesday May 15th started early. I got up at 6:00am and took a cold refreshing shower. My mind was spinning with day ahead so I had not slept well. The night before was a late one in the MSF base office as Luigi, our Italian project coordinator and I, were analyzing data regarding our surge in malnutrition here in eastern Chad. We sat in his hot, bug-filled office with laptops strewn across his desk.

I got to the office early in the morning. Everything starts early in Amtiman. The mobile clinic team arrives at work at the base at 6:00am everyday and the hospital medical team takes a Land Cruiser to the hospital at 6:45am. My plan this day was to go to the Ministry of Health (MOH) to meet with other non-governmental organizations (NGOs), UNICEF and the MOH to discuss the malnutrition situation. I prepared graphs and figures to explain to our partners the significant increase in cases MSF was treating. Before leaving, I scanned my email inbox to try to deal with a few urgent administrative and medical matters. Even at 7:00am, the office was hot enough to make you sweat.

Luigi, Andrea our mobile clinic nurse from Switzerland, Saintho our Chadian data manager and I took a Land Cruiser to the local MOH office. We greeted colleagues old and new. Our meetings began, and lasted five hours. During this time, different government, NGO and UNICEF representatives explained their current situation, problems and potential solutions. Luigi and I presented our data and together with our partners we discussed some concerted means to deal better with the situation. We did not necessarily agree on everything. After almost four months in Chad, I felt comfortable with MSF’s data and work.

MSF Chad malnutrition

MSF Land Cruisers at Kash-Kasha where we are treating patients with severe malnutrition. © Raghu Venugopal

 

When we finally got out of our meetings, I walked over to the hospital. I had not done my ward rounds, but I was starving and thirsty. I had a quick lunch at our house and then headed back to the office. I talked about construction plans with our logistical coordinator, Ibrahim, from Canada and emailed to the capital team requests for transferring patients. Ibrahim, Luigi our new German doctor Andreas and I all went back to the hospital. We found our new Irish pharmacist, Louise, and reviewed plans for our new pharmacy construction. We balanced size, cost and quality in our discussion. Then Andreas and I rounded in the HIV/TB service. The mid-day heat was difficult to tolerate with a surgical mask on our faces.

Many new pulmonary tuberculosis patients had arrived. Kadjija, a 30-year-old mother with pulmonary tuberculosis sat with her young infant on her lap. I explained to Kadjija and her husband that the child needed to be treated prophylactically for TB as well as Kadjija herself taking a full course of treatment for six months. Since Andreas was new to our project and on his first mission, I took time to explain to him how the ward worked and the cryptic short-hand I use in my medical notes.

After rounds, we sat down for a longer conversation in a private office with Yvonne and her one-year-old child. Yvonne’s baby had meningitis, severe malnutrition and tested positive for HIV. Yvonne herself tested positive for HIV as well. When I first met Yvonne, she said she was not sure life was worth living being infected with HIV, but the Chadian national staff and I have taken a lot of time with her to inform her that she can live a healthy life with HIV with the medications and services available locally. Yvonne’s baby needs to be put on antiretroviral medications for HIV, but I was not yet sure Yvonne had the degree of adherence necessary for life-long treatment of her baby. I discussed with our HIV team how we need to spend more time with Yvonne – addressing her fears and sharing information with her.

The sun was starting to go down when Andreas and I left the hospital. I went back to the office and sat down in front of my computer. Back to email and strategic discussions. I shuttled from behind my desk to Luigi’s office to grapple together with a myriad of operational, medical and human resources issues.

At 6:30pm, the regional UNICEF representative came by. Outside of formal meetings in the boardroom earlier in the day, we wanted the chance to talk informally. Luigi served up a warm Coca-Cola for each of us. The UNICEF representative had worked many times with MSF in the past, so when we finished talking at about 8:30pm we had found many common ideas on how to deal with our malnutrition surge.

MSF Chad

Dr. Andreas, our new German doctor, with curious village children in Amtiman. © Raghu Venugopal

 

Luigi and I sat down outside with the rest of the MSF team in the evening heat. Minutes later, and urgent phone call came from the MOH hospital nurse. A truck crash had occurred and many were injured. He said he needed our help.

I ran to my room and grabbed a flashlight, put on an MSF t-shirt and grabbed my stethoscope. Having dealt with this before, I knew extra hands were needed – so I ran to the rooms being occupied by our colleagues en route to the emergency in Tissi – and called on them for help. We piled into a Land Cruiser and went to the hospital.

The hospital was a collection of bystanders, trauma victims and cars transporting the injured. I waded into the triage department. I went right to the back of triage area, being careful not to step on any of the bloodied souls that were all over the ground. The quietest patient is often the sickest. So I started looking for these patients. I examined abdomens, chests, limbs and heads. I contributed to the triage effort – sorting out what patient needed surgery, what patient could be admitted to a regular ward for minor injuries and which patient needed to go to the ICU.

The collaboration between the MOH and MSF was excellent. Patient by patient we took care of everyone. Sigrid, our midwife from Germany, coordinated the operating room. Our colleagues on their way to Tissi – Carlotta from Italy, Matthias from Belgium, Kalyani from India, Zahid from India – they dispersed to the intensive care and wards to receive patients. Eve, our Canadian nurse, prepared the wards and obtained extra dressings. Carla, our doctor from Germany, treated our regular critically ill patients and ensured all the injured patients had adequate pain treatment.

One by one, patients were triaged to the operating room, intensive care unit, or wards. The worse cases included an unconscious young women with a severe head injury, two men with open arm fractures, another man with a leg fracture and a child with a head injury who was unconscious. In the operating area, patients lay on the floor covered in blood. We inserted intravenous lines, dressed wounds and gave strong pain medications while they waited for the surgeon.

Sigrid called me to the operating room. She was worried about the young woman with the head injury, undergoing repair to her scalp. There was a worry that she also had an injury in her abdomen. I examined the woman’s abdomen while the surgeon’s continued their work at the head of the bed. After performing an ultrasound of her abdomen, I was reassured there was nothing worrisome going on. But later, we performed a hemoglobin level and found the patient anemic. At about midnight we transfused her blood the intensive care unit. Because of MSF’s construction of a new maternity ward at the hospital, we could not use our usual mobile gurney to move the patient from the operating room to the intensive care. I found five men milling around and asked them for help. We carried the young women across the hospital compound in the dark, stepping on each other’s feet, stumbling time to time, but never falling.

The night went on. Everyone got taken care of. No patient died. Pain was treated. Patients and families were comforted. The hospital, already bursting at its seams with the malnutrition peak, somehow took on the 40 or so trauma victims.

We got home eventually later in the night. The day and night had been long. I had gone from base to boardroom to bedside, but somehow it all made sense. The best moment was being with our injured patients, getting everyone taken care of one by one.

The next day, I made a round of the hospital to re-examine the worst trauma cases. The unconscious young woman was now talking. I repeated her abdominal ultrasound and it was normal. The little boy who was unconscious was now walking round.

A day in the life of MSF is never predictable. Each day can change based on any kind of emergency. The days are long, it is still really hot here, and on Wednesday May 15th, I think the MSF team and I earned our keep.

Farewell for now from the house-call….to Chad.

Raghu

Note: all patient names are changed to protect patient identity

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Aimee’s pain was definitely real

Please note: all patient names are changed to protect confidentiality.

At 2pm on May 7th, Aimee, age 25 years, arrived at a primary care medical facility here in eastern Chad. She had abdominal pain radiating to her back and she had not had her menstrual cycle since April 18th. The treating medical staff did a basic exam and ordered some lab investigations. The clinical notes for her case are contained in a small notebook cut in half. Half a football player’s face is on the front. This is Aimee’s patient health record.  Most of the writing inside is practically illegible and incomplete. As is the case for most Chadians who seek health care in a cost-recovery setting, she was charged 4000 Chadian francs for what can best be considered an inadequate medical assessment.

A later documented medical note revealed Aimee continued with abdominal pain and was very agitated. For reasons that are unclear, she was given a perfusion of intravenous normal saline. Apparently, it was learned later that Aimee’s husband told the treating medical staff that his wife is often anxious around the time of her menstrual cycle. It was later learned that the treating medical staff felt that Aimee was indeed just anxious related to her menstrual cycle. Aimee was given a medication to relax her intestines as well as intravenous diazepam, a benzodiazepine medication used for limiting anxiety and causing sedation.

One of the most critical concepts for me as an emergency physician is “trust no one and believe nothing”. This even applies to information given to me by a well intentioned family members or fellow medical staff. These caregivers and caring people can give you misleading information, clouding your objective medical assessment. “Trust no one and believe nothing” does not mean to not listen to people. It is just a warning to keep an open mind to all possibilities and not fall victim to what we call “premature diagnostic closure”. A critical error by the medical staff that first attended to Aimee was accepting the easiest diagnosis possible and not considering first the most serious or life-threatening diagnosis for abdominal pain in a young woman who was likely pregnant.

Aimee later had a gynecological examination and she was found to have pelvic bleeding. She was still in a lot of pain as well, as the clinical notes revealed. For this reason, the primary care facility referred her to the Amtiman Hospital maternity service – nine hours after her first presentation with severe abdominal pain.

In the Amtiman maternity supported by MSF, the nurses and midwives on duty made a complete medical assessment. A legible, full medical note is written into Aimee’s health notebook. It turned out that this was Aimee’s second pregnancy and her main problem was intense abdominal pain. Vitals signs were completely taken and they indicated Aimee had a fever and was breathing abnormally fast. In my experience, the most neglected and yet revealing vital sign in medicine is the respiratory rate. Pain or shock are key reasons why the respiratory rate is elevated. Normally, it should be around 8-12 breaths per minute, but Aimee’s respiratory rate was 26. Not good at all.

In the maternity, rapid testing for malaria and syphilis were negative. A crucial pregnancy test was found positive. The maternity team on duty suspected Aimee was either having an abortion or ectopic pregnancy. They started an aggressive intravenous fluid bolus, gave paracetamol (Tylenol), and an oral iron pill (the last medication for a reason unknown to me). They decided they needed a doctor and an emergency ultrasound.

At midnight, our expatriate German midwife Sigrid called me. I had been sleeping poorly due to the heat. She asked me to go to the hospital to evaluate Aimee – particularly by ultrasound.  I said “no problem” and a few minutes later our driver and I were inside an old, rickety and dusty Land Cruiser on the way to the hospital. The night air was hot. Even though we were driving slowly, the potholes in the road made our bodies slam back and forth into the car doors beside us.

When I got to the hospital at 00:15, I greeted the staff and examined Aimee. I draped her shawl over her legs to protect her modesty. The nurses warned me it was covered with blood, but it was all we had. The nurses offered me gloves, but since I prefer to examine a patient’s abdomen with my bare, human hands – I declined. First however, I listened patiently with a stethoscope to Aimee’s abdomen. It was completely quiet, a bad sign that her intestines had stopped moving. I gently put my hand on her abdomen in different places and she winced in severe pain. There was no question at this point – she needed surgery – tonight. Aimee’s pain was definitely real.

I opened the suitcase I use for carrying the portable ultrasound and asked one of the nurses to hold the machine carefully. I put the ultrasound probe over Aimee’s right kidney on the side of her chest. What immediately appeared was an ominous finding that confirmed that she had an ectopic pregnancy (a pregnancy dangerously outside of the uterus). Not only did Aimee have an ectopic pregnancy – but it had also ruptured and she was bleeding internally. I have attached a photo of Aimee’s ultrasound– you can see her kidney (shaped like a kidney bean) with an abnormal black stripe around it (this black stripe is blood –evidence of intra-abdominal bleeding). The ultrasound exam of her uterus also revealed it was empty – which was further evidence of an ectopic pregnancy.

MSF, Chad, obstetrics

Ultrasound image of Aimee's intra-abdominal bleeding. The black strip (or sliver) between her kidney and liver is evidence of abnormal intra-abdominal bleeding. © Raghu Venugopal

 

 

At 00:30 I called our midwife Sigrid and our surgeon. Sigrid mobilized the MOH head nurse, operating room staff, and laboratory staff. She came herself to the hospital to make sure everyone did their job. Aimee was in the operating theatre at 01:10 and at 02:40 the surgery was finished. The surgeon found a ruptured ectopic pregnancy and was able to remove the abnormal pregnancy and stop the bleeding. A blood transfusion was started at 03:22.

Today is day six after Aimee’s surgery. She is having fever still and is being treated with three antibiotics. She is also being treated with strong pain medications. But she is able to sit up, to shake hands with me, and to smile when I took a photo of her with her consent.

Obstetrics, Chad, MSF

Aimee on day 6 following her surgery. She's able to sit up and smile (photo is with patient consent and the patient's real name is not used). © Raghu Venugopal

 

 

Aimee’s pain was definitely real. Her case highlights gaps and problems in the Chadian health care system and why maternal mortality is so high in this country. Qualified medical staff are lacking. Basic and life-saving health care is unaffordable to the rural poor. On a positive note however, the MSF supported medical staff recognized the seriousness of Aimee’s pain and sought timely help. For the future as well, I am teaching the Chadian midwives and nurses how to use ultrasound to answer basic clinical questions. I hope they will use ultrasound, with support from future doctors, after I return home.

Aimee’s pain was definitely real. And she is definitely better now.

Farewell for now from the house-call….to Chad.

Raghu

 

 

 

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What will day 58 bring?

I only have four weeks left in Chad on this mission. The days have been long. I am exhausted. I skipped my last chance at a break to not miss one of the most critical MSF planning exercises of the year. I miss my fiancé Maeve very much. I think I have grown somewhat used to the heat, but it is still the hardest part of being here on mission. Last night it was hot and humid. I took a warm shower and collapsed in my bed. The shower is my favorite time of day – when my whole body is cool – just for a few minutes.

Today, Sunday, I tried to sleep in. It’s no use. My internal time clock is now wired to 06:30am. I don’t need an alarm clock anymore. I used the time today to sit on the floor alone in the cool pharmacy storeroom to work on Amtiman’s “4M” plan. The 4M is the time when, with four month’s worth of data, we adjust and change our annual planning. I needed to be alone to think and type on my computer to do this work. By the time the rest of the team had come back from an “explo” or exploratory-trip to a distant health center, I had re-drafted our 4M plans and was working on regular MSF matters by email. Sunday should be a time to rest, but it’s also really the only day of the week when it is calm enough to think, blog, and deal with email. It is a staple workday.

Things like planning for the 4M and email is thankfully interrupted by what I know best: hospital rounds. Let me take you on a walk on our rounds. We’ll see a few patients including David who has had 57 days of fever.

These days I am covering for Dr Guy in the hospital; we deployed him to Tissi to respond to the refugee emergency at the border of Sudan, Chad and the Central African Republic. Dr Guy is now on a well-deserved vacation and our Dr Johanna has replaced Dr Guy in Tissi. As medical team leader, I fill in the holes in the project that need to be filled – like when team members go on a needed vacation, are sick or are loaned to other sites. Positions I have covered lately include our lab supervisor, hospital nursing supervisor, midwife, project coordinator and outreach supervisor. But my favorite position is just medical doctor.

Let’s take a walk in the hospital together. We can go to the HIV-tuberculosis (TB) wards where Dr Guy usually works, but where I am covering now. It is quiet, and dust and flies are everywhere.

Mariam is 40 years old and came to hospital on April 29th. She had massive swellings on the right side of her neck. Suspecting she has TB of the lymph nodes, we are treating her with four TB antibiotics and are planning to test her for HIV. By examining Mariam and doing some basic blood tests, I do not think she has an alternative diagnosis like cancer, but it is hard to be totally sure. We’ll have to confirm Mariam’s diagnosis based on how she does day to day.

Saad is a 13-year-old boy who lives in a village far away. He was started on TB medications in December 2012 for extrapulmonary TB. Since he lives so far away, he takes MSF’s mobile clinic Land Cruiser to come to the hospital to receive his medications each month. Saad is a friendly young man. He grins ear to ear when I greet him. The nurses tell me he takes his medications perfectly.

Hasan is 38 years old and has active pulmonary tuberculosis. I always where a mask when I examine him, or any other patient possibly with active pulmonary tuberculosis. I have already contracted TB once during my first mission in Burundi with MSF, and had to take nine months of medication myself. I don’t want to be exposed to it again. Hasan is coughing a lot and when I listen to his lungs it sounds like rubbing your own hair between your fingers close to your ear. It crackles. I breathe lightly through my mask when I examine Hasan. I don’t want to get TB.

Abakar is very sick. He is critically ill with HIV and has a CD4 count of only 26. When we first met, I found him with a severe systemic infection, severe anemia and in distress. He had a strong cough, and I presumed his lungs were infected with TB. His left arm was very swollen and tender. Flies were everywhere when I examined him, on Abakar and on me. I gently moved his elbow and it cause him much pain. The bones cracked as I moved his elbow as slowly as possible. I asked twice if he had fallen. His family kept saying no, and I believed them. I pulled out my ultrasound and moved it slowly over the swollen areas – they were fluid filled and infected. I had our surgeon drain the infected fluid from the elbow area – it was serious the surgeon said. Sitting on the edge of Abakar’s bed I realized that not only did Abakar likely have TB of his lungs, but TB of his left elbow as well. The TB had infected the joint and bones, and that explained what I was seeing. We will stabilize Abakar on antibiotics, intravenous fluid, blood transfusions and TB treatment, and then start him on antiretroviral drugs for HIV. I am really worried about Abakar that he could die. We’ll do our best to cure him.

David has had fever for 57 days. His cough is strong and his lungs sound horrible when I listen to them. He is very thin and he has active pulmonary tuberculosis. Despite being on TB medications, and other antibiotics I have added to treat him for other infections, he won’t stop having fever. Dr Guy, and now me, have considered and tested him for many different pathologies – including HIV and malaria – but we can’t get his fever down. We used paracetamol (Tylenol) and ibuprofen to make him feel better, but the fever always returns. I suspect David has multidrug-resistant TB. In three days we’ll test his lung sputum again and I suspect it will still show he has active tuberculosis. Everyday when I examine David his mother is on the floor sitting next to him. We all shake hands.  David makes a soft smile each time.

Issa is our last patient for the moment. He is 25 years old and has been hospitalized for 23 days. When he arrived, we diagnosed him with a serious infection around his right lung. The right lung was floating in infected fluid. My portable ultrasound confirmed it was fluid around his lung before we inserted a needle and then tube in the space outside of his lung to drain the fluid. Despite the chest tube, I examined him a second time by ultrasound and realized the first chest tube had not drained the fluid entirely. I sent Issa back to the surgical theatre and they removed 350 milliliters more of infected fluid. Issa has had a lot of pain lately with all the drainings. I found the keys for our special locked box where we keep narcotic pain medications and filled out the forms needed to remove a small quantity for our nurses to give Issa. Issa later said the medications helped a lot with his pain and he looked more comfortable.

Thanks for taking a walk with me today on a short round of the HIV-TB ward. I wish David’s fever would not last 58 days, but I fear it will. It must be hard for him to have fever so long, especially with this heat. Even the local Chadian people find it hot. But we’re trying our best to help David. I hope day 58 tomorrow will be a better day for David.

Farewell for now from the house-call….to Chad.

Raghu

Note: all patient names are changed to protect confidentiality.

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Malnourished children and displaced people

We all knew that late in the dry season, malnutrition would peak. But this week it hit us hard. Our outreach teams had difficulty coping. The hospital was temporarily over-run. Dr. Johanna, our MSF doctor from Sweden, told me the hospital “looked like a refugee camp”. The team and myself surveyed the hospital grounds. Two patients shared a bed in some circumstances; the area we use for children’s play was covered with mattresses on the ground and patients; and our tent used for epidemic infectious disease was filled with malnourished children.

I quickly emailed our nutritional epidemiological data to our medical coordinator, Cristina, from Spain – she coordinates our medical operations from the capital and has many missions of MSF experience.  She quickly produced some graphs for our team and provided medical direction. The increase in our malnutrition curve had never been so steep in the past four years. The following graph can give you a sense of the spike in cases we are seeking now and the seasonal rise in malnutrition in 2012 (TFP stands for therapeutic feeding program).

MSF malnutrition programme

 

Quickly, we started making plans to deal with the increased numbers. Stefano, our Italian MSF head of mission, and Luigi, our Italian MSF project coordinator quickly met with me in front of an erasable whiteboard.  I outlined the mobile clinic situation. We quickly agreed on an action plan based on the data and our team’s input. We would immediately add five staff to our mobile clinic outreach team. Andrea, our Swedish mobile clinic expat nurse, sat down with her Chadian team and made a plan to support the hardest hit health centers. Our Chadian hospital supervisors shifted nurses to the malnutrition wards to aid with the increased numbers. Gardy, our construction logistician from the United States, started constructing new beds and putting up a new patient tent. Oliver, our supply logistician from Germany, starting having new mattresses made.

The same day the mattresses were delivered to the hospital and the next day the bed frames were ready. Within one to two days the extra outreach team members were hired and deployed. At some point we had 50 children in the malnutrition service and 43 in the pediatrics service. The doctors, nurses and nutritional assistants worked extra hard this week. The intensive care was completely full. But at the end of the week, the situation was stabilizing. A new reality was settling in – the malnutrition season was here in force.

At the same time, violence to our east had erupted. In the Tissi region just east of Amtiman, tens of thousands of displaced civilians poured into eastern Chad from Sudan and the Central African Republic. Internal to Chad as well, the population was displaced in this area with a tri-border between Chad, the Central African Republic and Sudan. Violent clashes in neighboring Darfur had lead to about 50,000 people fleeing. Our MSF mission responded swiftly. Lead by our MSF Chad Emergency Response Unit (CERU), our team was providing vaccination against measles, primary health care, emergency medical care and clean water.

Our Amtiman project pitched in to help the emergency response in Tissi. Our site became a strategic operational base where staff and logistics could be funneled to Tissi. MSF emergency response staff came in, got ready for Tissi, and shipped out by Land Cruiser or plane. We made a decision to deploy our Congolese expat doctor, Guy, to Tissi. I knew conditions there must have been difficult. He texted me after he got there – asking me to send a towel, soap and toilet paper. He got it the next day with Claudia, an MSF nurse from Germany, here on her eighth mission. Claudia had recently been evacuated by MSF from the Central African Republic, to our south, after their own violent change in regime. She had quickly agreed to come be part of our mission in Chad.

Soon, our Amtiman physician, Dr. Johanna from Sweden, will head to Tissi. It will make our work here harder losing her temporarily – but we all have to dig a little deeper when an emergency strikes. Everyone in our team is being flexible. That is a watchword in MSF work – flexible. We need to be flexible and nimble at all times – able to shift and adapt to the ever-changing local circumstances. While we have our ethics, our founding Charter and our operational plans as a backbone of our operations, everyday here I learn that our role shifts and evolves all the time.

Otherwise, the last week for me has been tricky. I’m covering for our expatriate hospital nurse who is on vacation and also Dr. Guy’s usual responsibilities in the HIV/TB service. Our laboratory expat is also on vacation, so I cover her position as well. One has to be flexible. We’re also entering a major planning phase for the rest of the year with our medical data for the past four months. It’s very busy.

To our surprise last night, a huge sand storm was followed by rains for a few hours. The usual searing heat fell. The team and I sat outside last night savoring the cool weather of about 26 degrees Celsius. When the rains started to fall, I was skyping with Maeve, my dear fiancé in Canada. We miss each other so much. I said good-bye and ran back to our house to move my bed inside because of the falling rain. Lately with the heat, I was sleeping outside. Last night however, the whole team slept inside our tukuls – or little huts – and slept royally because of the cool breeze. After the heat, it will soon cool with the rainy season coming. The rainy season – though welcome – will bring new perils for the people here. Inaccessible roads, malaria and cholera are on the horizon. But we will be here. And we will be flexible.

Farewell for now from the house-call….to Chad.

Raghu

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Late at night

On April 4th late at night, Dr. Guy called me from the hospital. A child had fallen from the roof a house. He asked me to come to the hospital and bring the portable ultrasound machine since he was concerned about a serious abdominal injury.

When I got to the hospital I met Ousmane and his father. The first thing we did was shake hands. Ousmane was 13 years old and was brave and calm. I put my hand on all parts of his abdomen as gently as I could and he winced in pain. Since I graduated from medical school 12 years ago I have come to know that look of pain on a patient’s face well. It indicated to me a grave surgical problem. A hole in the right lower quadrant of Ousmane’s abdomen indicated a place where a stick or piece of wire had puncture and maybe entered his abdomen. I turned to Guy and told him I was worried. Guy and I agreed this was what we call a “surgical abdomen”. I told him we did not need an ultrasound to convince us to take the patient to the operating room.

Nonetheless, I performed the ultrasound of Ousmane’s abdomen and it was normal. Very often, in the acute stages of a serious abdominal injury with perforated intestines, the ultrasound is unremarkable. This was a clear case where the physical examination of the patient was a 100 times more useful than technology.

MSF Chad

Ousmane's hand hand and intravenous line when he first arrived. © Raghu Venugopal

 

While I prescribed three antibiotics and intravenous fluids for Ousmane, Guy called the surgeon and the surgical team. The MSF car left the hospital in the night, collected all the surgical team and returned. When the surgeon arrived, he took what seemed five seconds to examine Ousmane and agreed on the need for surgery. Within minutes, Ousmane was in the operating theatre. Later yet in the night, Guy informed me our clinical suspicion was correct, the intestines had been perforated. The surgery had gone well.

Ousmane was moved to the intensive care unit. The first days and nights were hard for him. He needed a lot of pain medications. Late at night on April 6th the nurses called me during my overnight on-call duty. They said Ousmane was unwell. I got out of bed and changed quickly into pants and a shirt and took a Land Cruiser to the hospital. The night air coming in the window was hot. The dirt streets were empty. The dust and darkness made it seem like we were driving in fog. It was calm and peaceful. The driver and I drove in silence.

I got to the hospital and examined Ousmane. He was delirious and nauseated. His father shared the bed with him and I could see he tended to him as best he could. I talked to the nurses while I examined Ousmane. Then I prescribed medications for nausea and talked to Ousmane’s father through the help of the nursing staff. Ousmane was having a rocky post-operative course.

With other doctors on the team taking care of him, and with many things going on in my daily non-clinical work, I honestly somehow forgot about Ousmane in the subsequent days. But on April 13th, I was quickly walking through the pediatrics ward and was stunned to see a young boy with a huge smile from ear to ear. It was Ousmane. He was about to go home that very moment, and he had completely recovered. He was a lovely young man. I asked him and his family’s permission to take their photos and Ousmane did great taking his own photo with my iphone.

MSF Chad

Ousmane on the day of his discharge smiling ear to ear. © Raghu Venugopal

 

As a medical team leader, I don’t work as much in the hospital at night compared to the rest of the medical team of nurses, midwives and doctors. These men and women work long and hard. In some cases, expatriate medics are needing to work seven days a week in the hospital. It’s hard and wears you down. My own time is heavily spent on medical strategy, coordinating our efforts with the Ministry of Health and other actors, and doing the behind the scenes work that is crucial to ensure a hospital and outreach team can do their job. I’ll be honest with you, that I prefer the bedside medical care – in the day and in the night.

It is possible to think of MSF’s medical work like a scalpel, which we use during surgery. The sharp end is at the bedside with patients and families. It’s the crucial end – and nothing can replace it. But behind the blade is its attachment and then the handle from which to hold the blade. These parts are crucial too. I prefer being at the sharp end – but I know the attachment and handle is just as important. You can do much with just the blade.

Behind able to go to the hospital at night requires a proverbial blade, its attachment and a handle. Practically speaking we need drivers, cars, petrol, guards and radio operators to make it happen. We need nurses on duty, who first discover something is wrong. We need logisticians who ensure there are generators to give light to the hospital at night. We need non-medical team members to also order key medications that I or other medics might prescribe at night. We need a coordination team in the capital to reach an agreement with the Ministry of Health that we can work here in Amtiman. And we need donors and supporters who generously give to make all of this possible.

Late at night we need a doctor. But we need a lot more too.

Farewell for now from the house-call….to Chad.

Raghu

MSF Chad

Ousmane does a great job taking his own photo with my iPhone. © Raghu Venugopal

Please note: patient names are changed to protect patient identity.  All photos are posted with family consent.

 

 

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Ali’s cough

Ali is 36 years old and has been coughing for a long time. He has been coughing since at least 2006. When we first met each other and shook hands I was happy to learn he spoke French, so we could talk directly. We did not need a translator from French to Arabic.

The majority of our patients here in Amtiman speak Arabic. I’ve learned a number of Arabic phrases here to adapt to the local culture. They are mostly words and phrases I use when seeing patients. Being able to speak a few words of Arabic to each family makes me feel our connection as patient and doctor is somehow a little closer than if we just communicated through a translator. The following Arabic words I mostly use for seeing pediatric patients, and they include:

· Hello, how are you?

· Is your child a boy or a girl?

· What is your child’s name?

· How is your baby?

· You have a beautiful baby!

· You have a really beautiful baby!

· Can you please breast-feed your baby? (a baby not able to breastfeed is a concern)

· Please remove your child’s clothing.

· It is really hot today!

· It is really, really hot today!

· No problem.

· Slowly, slowly – things will get better.

· Congratulations – you can go home now!

I was called to see Ali on my mobile phone by Dr. Guy. Guy is our Congolese expat doctor who follows our HIV+ and tuberculosis (TB) patients. I was working at the MSF base on my computer and Guy’s call was a welcome change from sweating behind my computer on seemingly endless, important emails.

Dr. Roland, a German doctor with MSF, had just arrived from Berlin to our base to evaluate the quality of our medical operations. I passed by the MSF house, we shook hands quickly and I asked him if he wanted to immediately go to the hospital. He agreed.

When we got to the hospital we found Dr. Guy and Ali in the HIV and TB clinic office. He was joined by our Chadian HIV-TB nurse Theophile and our HIV-TB counselor Jean-Blaise. The mid-day heat was about 41 degrees. Ali was coughing and I immediately asked everyone to put on a facemask, including Ali.

TB MSF

Ali (not his real name) most likely has multidrug-resistant TB (photo with Ali's permission) © Raghu Venugopal

 

Guy presented Ali’s medical history and we all listened. Ali was diagnosed with HIV 11 years ago. He took anti-retroviral  medications, but was not adherent all the time. Ali did not know his CD4 count – a measure of the strength of his immunity. Unfortunately, as well, Ali had been treated for tuberculosis a total of four times – but had never achieved a clinical cure. He had been treated for TB in 2006 for six months, 2007 for eight months, 2010 for eight months and again started TB treatment in October 2012.

Guy called me because he suspected Ali had multidrug-resistant TB (MDR-TB). MDR-TB is a major concern of MSF’s since it is under-diagnosed and undertreated around the world. When the diagnosis of MDR-TB is made, the treatment is very difficult. It consists of painful injections everyday for the first eight months and then up to 20 pills a day for two years. The treatment also has significant side-effects including nausea, bodyache, rashes, permanent deafness and psychosis.

MSF is deeply concerned that this current approach to treating MDR-TB is too long, too toxic and too costly. Each course of treatment costs about USD $4000. These reasons are why MDR-TB is so important to MSF and why we are working with the Chadian Ministry of Health to improve the diagnosis, treatment and advocacy effort on MDR-TB. Critically, MSF is also supporting research on better treatment regimens.

To make the diagnosis of MDR-TB for Ali, we decided to contact our MSF TB and laboratory colleagues in Europe for advice and try to send Ali’s sputum to Antwep, Belgium, for confirmatory testing. We also plan to test Ali’s sputum when a new sophisticated machine, called the ‘Genexpert’ arrives in Amtiman in May. The Genexpert is a significant advancement in the diagnosis of TB and drug-resistant TB. Rather than needing sputum from deep in the lung for diagnosis we can just use saliva from the inside of a patient’s mouth.

As well, we can improve the detection of TB in children with the Genexpert. Children are highly susceptible to TB infection and are notoriously difficult to clearly diagnose. With the Genexpert we can pass a small tube from a child’s nose to their stomach and remove some fluid to test for TB with greater reliability than ever before. To prepare for the arrival of this new equipment, MSF is sending its Chadian and expatriate lab staff to regional expert trainings in Nairobi and upgrading the logistical ability in our hospital laboratory. We will also invite an MSF TB expert from London to join us for a few weeks in June to support our local efforts.

Ali’s problems were not just his cough however. In addition to being gaunt and cachectic [physical wasting with loss of weight and muscle mass], he had dark, purple-ish lesions inside of his mouth. Guy, myself and the team looked at the lesions and suspected a form of cancer, called Kaposi’s sarcoma. We were not entirely sure however. With Ali’s permission, we took a photograph and last night I uploaded it to the MSF telemedicine website for external support from an HIV expert. This morning, 12 hours later, an MSF HIV expert confirmed the photos we uploaded from Chad were indeed Kaposi’s sarcoma. The expert also included three scientific articles for Dr. Guy and myself to read to improve our knowledge on this topic. I was amazed at the speed and quality of the telemedicine support.

MSF is working with the Chadian Ministry of Health to aid patients like Ali. Our first goal is to make the right diagnosis using our clinical judgment and appropriate technology. Our next goal is then to use the right drugs to try to cure Ali. An option is not to keep using the same ineffectual drugs for Ali – which may only worsen his suspected drug-resistant TB. Médecins Sans Frontières is bringing all of these resources to bear to help patients like Ali. I hope, 2-3 years from now, Ali’s cough is gone.

Farewell for now from the house-call….to Chad.

Raghu

Please note: patient names are changed to protect patient identity.  Ali’s photo (not his real name) is posted with his permission.

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