Masked marauders, criminals and HAART

Greetings from Hawassa!

A Friday afternoon is lovely in our apartment on the third floor in the middle of the fields from which has sprouted Hawassa University. The corn thresher across the dirt road is active, the cows are still in the harvested corn fields, the funny, gregarious bird with the black mask that loves our porch window is raucously calling us, my work at the hospital is done for the week, it is 80 degrees and sunny and life is sweet.

Went to the ICASA (International Conference on AIDS and Sexually Transmitted Infections in Africa) last Saturday, but ended up returning 2 days early. Became sick in the middle of the night on Monday (I am beginning to think it was altitude sickness, because the same thing happened the last time I was in Addis Ababa) and returned on an overpacked (fifteen people in a vehicle that should hold 12) van with friends Walalign and Besa. It was an experience. There no longer is a bus station in Addis but everyone knows to go to a particular section of the city and wait for the vans to drive by with the young men yelling out their destinations. The van doesn't leave till it is (over-) full. So you can take an hour driving around doing the “collecting”. Then five hours down a crowded, bumpy road filled with lorries, buses, vans, cars, bicycles, people, cattle, sheep, goats and sometimes accidents. At one point we stopped to observe a crowd of twenty or so neighbors and passersby desperately trying to pull the driver out of a smashed-up van. No ambulance or emt or jaws of life or even police or fire department. Volunteer human power, which is usually what Ethiopians must rely on.

Arrived in Hawassa nearly crippled from knee pain from being doubled up in the van, but happy to be home. I truly appreciated the conference. Gazillions of papers and posters on the massive human experiment that has taken place throughout Africa in the last 5 years, the transformation of the treatment of the AIDS epidemic by implementation of broad-based, free highly active antiretroviral treatment (HAART). It has been a monumental and heroic effort to get the meds to every isolated corner of the continent, including Hawassa, so that people whose imminent deaths were considered a foregone conclusion, are now facing the possibility of watching their children and grandchildren grow.

There has been so much data gathered in the course of this incredible ongoing experiment, and a lot of it was presented at ICASA. I felt very fortunate to be able to hear and read about the struggles to reach the most at risk – sex workers, men who have sex with men, immigrants and migrant workers, and the small but growing number of injection drug users. The papers were broad-ranging, from when is the best time to start HAART after beginning a doubly-infected person on TB treatment, to how to follow people's clinical course when you have minimal laboratory capability, to preventing transmission by empowering women through education and employment. All around me different languages being spoken but, the most impressive thing to me, the science was by and large being carried out by Africans in their own countries. And though this may be influenced by sampling error – after all the conference was in Addis – I found the best presentations, the most concrete, data-driven and clinically useful, to be Ethiopian. I was heartened and proud.

The over-arching issue, though, was that of sustainability of treatment. In this last year, the United Nations Global Fund which, with the US PEPFAR, has been the main source of funding of AIDS treatment, had its donations cut by about 10%, which is a major blow to the capacity of the African medical systems to treat the disease. The accomplishments so far have been amazing: reduced transmission and death rates, vastly decreased Mother to Child Transmission, increased identification and treatment of tuberculosis, but all at huge cost. Is this going to be lost to the global recession?

There were political struggles over this question, and it was good to hear them. Many of the true AIDS heroes, Peter Piot and those who struggled for HAART treatment in Africa, demanded that funding continue and expand, while others babbled (editorial comment) about Africa “owning” the funding. This smelled rottenly to me of neo-liberalism particularly when a Nigerian spoke of African nations adopting systems of private health insurance. Wait a minute! Is that not the same system that has left 48 million in the United States without care?

One of the best lines in the conference came from the Archbishop of the Ethiopian Orthodox Church, who was being pressed about his Church's (reactionary) position on condom use and anti-homosexuality. He side-stepped those issues (unfortunately) but instead said that Jesus' main tenet was that the rich should give to the poor. Pretty simple, I would say.

I never had a chance in this crowd of 10,000 to mention that the necessary billions could easily come from the over $800 billion US military budget or from re-taxing the Bush billionaires. They were the elephants in the African room.

I did find myself compelled to react when Prime Minister Melas of Ethiopia gave George W. Bush a medal for his role in initiating PEPFAR. I did not disrupt the meeting. I did not want to get arrested and particularly didn't want to get kicked out of Ethiopia. But boy, that is one disgusting, greedy war criminal! So when folks were clapping and standing, I stood up and turned my back. Interestingly enough there were three African women behind me who did not stand up but who smiled and nodded. I shook their hands and that was it.

I am glad George Bush did PEPFAR, despite his intent through it to further enrich the coffers of the pharmaceutical companies. And I am glad for his new proposal, to detect and treat African women's cervical cancer, which is in many countries here the top cancer killer of women and is associated with HIV infection. Good. But it doesn't make up for hundreds of thousands killed and millions made homeless (subjecting them to risk of HIV tuberculosis and STI's, among other fates) in Iraq and Afghanistan, or his anti-gay and anti-woman and anti-poor policies that all worsened the HIV epidemic in the United States.

Enough!

Back in Hawassa it was the week for clinical testing of the first year medical students. They presented the history and physical exam of a designated patient and I was one of the examiners. It brought back in spades all the anxieties of medical school for a shy and hesitant student. (Yes, believe it or not, there was a time when I was painfully shy!) The Ethiopian examiners are pretty rough and I keep finding myself playing the “good cop”. I am impressed, though, by how hard these young people, who have so little resources, work to learn their medicine. I think I have said in past blogs that I am truly and unexpectedly enjoying teaching.

But I am still upset at the lack of resources. For my clinical friends, we do not have the basics of asthma treatment – no nebulizers! There is one man who is in severe respiratory distress, might have been intubated by now in the States, and is not being adequately treated. I have called all around Hawassa to try to get the machine we need – no luck. The one medical supply store in town says they will order them. I hope he is still alive by the time we get what we need. I have bought peak flow meters, but without the medicine to treat, they are fairly useless.

I will be coming home to Northampton on December 27 and hope to see as many of you as possible. Am going to try to get Elliot to write more, as his work at the University is getting interestinger and interestinger.

In the meantime, I miss you and hope you are well and constantly learning.

Love,

Marty and El