One of the things I have always liked about being a doctor is the variety. A typical day at work in a busy tertiary hospital in Sydney can involve ward rounds, counseling patients and their families, attending multidisciplinary meetings, teaching medical students, reviewing patients in the emergency department and spending time reading articles, doing research and discussing quality improvement in health systems.
But hospital life has nothing on MSF. My job here is a mix of field TB doctor and research co-ordinator of a medical research study looking at new ways of treating multidrug-resistant tuberculosis (MDR-TB).
A typical day here can include visiting the TB clinics to conduct monitoring and evaluation of their TB health service, running training sessions for the local TB doctors, reviewing patients in the clinics or in home visits, meeting chief doctors to discuss issues of staffing and resource allocation, advocating to local institutions on issues relevant to TB care, discussing patient management with our Karakalpak medical colleagues, checking with our supply logisticians when our next cargo of TB medicine is likely to arrive in country, planning how to implement new drugs for the treatment of MDR-TB or poring over excel spreadsheets of data for our research study.
It is all pretty fascinating. Except the excel spreadsheet part.
Sometimes after a few days in the office, swamped with meetings, discussions and excel spreadsheets, I find myself unexpectedly in the field reviewing a patient who is having side effects or a complication of their treatment. Despite all the excitement and the novelty of the many facets of working with MSF, it’s seeing patients that I still enjoy the most.
Today I went to visit Lola*, a 65-year-old lady who has MDR-TB and is one of the patients in our research study, using a newer and shorter combination of drugs to try and cure MDR-TB. She has been having some complications of treatment and needs to be reviewed.
When we arrive at her house – myself, my interpreter and a nurse – it is the first time we have met, and I am aware of the imposition we have created. The three of us have just turned up, unannounced, looking strange and alien like in our respirators. All the health professionals wear them when visiting patients, as part of infection control measures to reduce the spread of TB and protect ourselves.
Her daughter and grandson are preparing vegetables, peeling carrots, eggplant and garlic. Immediately her grandson jumps up to find a kurpacha, a traditional quilt mattress, for us to sit on. He then comes to each of us, shaking our hand and offering his greetings. In Karakalpak culture, the common greeting is the handshake, and everyone joins in, regardless of age or gender. Karakalpaks are notoriously hospitable people.
Lola doesn't seem shy of us, three strangers who have suddenly turned up. She launches immediately into telling us what has been happening. She wonders why we have come to do an electrocardiograph, to measure the electricity of her heart, when the same test has already been done twice in the last three days. She tells us of her many symptoms, palpitations, tremors, sweats, cold feet and dizziness.
She tells us of how every morning, she wakes up early and begins to feel dread, with the anxiety mounting until the time comes for her to take her TB tablets. She describes a sense of fear, it grips her around the heart and makes her feel shaky, she tells me.
I ask her some questions about her symptoms, trying to discover whether she is having symptoms that are likely coming from a heart problem. A lot of what she is describing sounds like anxiety, to me. It’s very common for TB patients to suffer from psychological problems. For many, the diagnosis of TB is a huge blow, causing a lot distress for them and their family.
We check her over and repeat the electrocardiograph. It shows an abnormality and I explain to her that we will have to temporarily stop her treatment and run a few tests.
Her daughter asks me if it's OK for her to drink camel's milk – widely thought to be helpful in combating TB. I explain that she should eat and drink anything that she enjoys, but it’s very important for her to take her medication as instructed.
Lola explains to me how, over the eight months of her treatment, she has been dedicated to never missing a single dose. She tells me of how she convinced herself to be strong, to push forward, not to give up and to take her treatment, for the sake of her children. Of how she never missed even a single day of her medication.
That despite worrying every morning about the inevitable fact that she would have to take the tablets, she also waited in anticipation of the nurse to bring her the treatment, so she could feel that each day she was progressing. ‘I am most worried that something will go wrong, and I wont be cured. How are my lungs? Will I be cured?’
The truth is, it's a hard question to answer. There are no guarantees in medicine, and with these forms of TB, it’s hard to be able to guarantee a patient of a favourable outcome, even when, like Lola, they take all their treatment perfectly.
I try and reassure her as best I can, that she is responding to her treatment and I am very hopeful of a good outcome. She thanks us, hand on heart, for coming to see her. She seems a little less anxious than when we first arrived. She gives us a brilliant smile, a full row of golden, gilded teeth flashing.
*name has been changed