The concillium is an event attended by various senior figures of the TB world here in Dushanbe. The venue, the TB dispensary, seems the perfect placefor informed discussion and teaching. This is my second week here in Tajikstan and we have three patients to present.
Bobojon, the dutiful doctor preps the patients beforehand (as well as they can be) and will present at the event. Two of the patients are sick in the hospital and therefore, consideration of treatment needs to be discussed as soon as possible. We have taken into consideration that the children may need treatment but we do not have the drugs until end of November 2011. MSF have agreed to buy the relevant investigations, the food and the drugs for these three patients from MoH before our own supply arrives. We think that the children are sick, and by considering treatment for the children, we can help with their health and decrease transmission.
The concillium is attended by the MDR coordinator for the region, a friendly figure, with whom I have had a lengthy discussion about the patients. My close allies are my trusted translator, observing every change in body language or tone of discussion, and the office assistant discretely positioned out of sight. I do not recognize the other three bodies in the room, but they seem to be of authority. With the greetings of assalom aleykum and a gentle placement of the right hand on the chest, I am offered tea. The forum has started; the initial calm a false shadow of what is to become a difficult event.
The first patient, a 13 year old girl, has multidrug-resistant tuberculosis (MDR TB), based on her diagnostic investigations. This girl was diagnosed with TB in March 2010. She has been under conventional treatment for a long time but the bugs have become resistant. This result of the resistance was known back in May 2011 but there were no beds for admission, an explanation for which I have not yet heard. She remains in her community until we can locate her and bring her in for an assessment. The concillium are in agreement that this is MDR TB.
The next patient presents a challenge. I notice that the conventional manner of the presentation by the doctor starts with name, age, region and then straight to result of HAIN, a rapid screen for resistance to drugs. The decision is made that we cannot discuss the patient until the HAIN result is known. I speak because there seems to be an injustice to the patient, who I and the hospital doctor believe is sick and infectious. We are presented with no narrative for this patient, and if there was a fly on the wall, it might be mistaken into thinking that the patient's name is actually HAIN. We talk about investigations which may be incorrect, especially given the fact that the lab may not be one hundred percent accurate here in Tajikistan, but the understanding of sensitivity and specificity is not fully understood. I ask why the patient might be failing treatment and the response suggests that the patient is to be blamed, "the patient did not follow the instructions" (a further injustice to the patient whom this team of people know nothing about – I also remind myself that the patient least likely to comply is the one least likely to be able to). I try not to gain the position of an unwanted guest and adjust my calm. I plead that we consider the narrative and repeat clearly that we are doctors who look at history, examination, investigation all of which are taken in context of the clinical history. I fail, and subject moves swiftly over to the next patient we wanted to discuss.
Our patients will be discussed at the next concillium. I pass the cups of tea back, show my respect with the Tajik ‘thank you’ and with learnt manner, I smile as I walk out.
I have met with many people of authority here, all indivdually wanting to improve the care of the children. I have no doubt that the doctors care about their patients, but I think they are subject to forces, likely to be economically driven, which ulimately govern how the doctors practice medicine. The doctor in the hospital is good, but he is torn between the demands of the commissioners (every day over the last 2 weeks), the chief doctor (who sits quietly in his office watching daytime TV), and the doctors of the TB programme in general. But in my heart (perhaps naive) and irrespective of money, there is a code that we all follow when we become doctors, the code of duty to our patients. And I remind myself of this, a fortunate reminder in fact, when I go back to the hospital after the concillium; the children are dutifully in bed, but with the odd delinquent still awake, they share a smile and the patient we discussed does not look as bad as she last week, but still sick and in need of treatment. The medical need is great but the forces that will affect change can only come from the highest authorites. This is going to be a personal challenge.