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