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Wednesday, October 17, 2007

Inefficiency and injustice

Wednesday at Nyahuka Health Center brings HIV+ patients from out of the woodwork of Bubandi, Busaru, and Ndugutu sub-counties. Most of them live sort of invisibly, keeping a low profile, hiding from public places. Perhaps a hundred of these patients at various points along the HIV progression timeline shuffle in for “care and treatment.” “Care” is defined as the provision of antibiotic prophylaxis (cotrimoxazole) and treatment of opportunistic infection (plus or minus compassion), while the term “Treatment” is reserved to include the prescription of ARVs (anti-retroviral drugs, highly active three drug combinations).
Today I (Scott) shouldered the responsibility of seeing all those HIV+ patients who needed to see a doctor, either because they had a medical problem or because they needed their ARVs re-filled. If a patient wanted to take porridge provided by the Kwejuna Project, listen to the bible teaching, and get their cotrimoxazole refilled, they could do so without waiting to see the doctor.

After finishing with few obstetric ultrasounds, I sat down in the examination room and began the long process of seeing these extremely complicated patients. The spry, smiling Costa (nursing assistant) bounced in and said, “So, doctor, what will you be prescribing today?”
I responded, “The standard, I suppose: CombiPak - Zidovudine, Lamivudine, Nevirapine. Isn’t that the only combination we have?”
He cheerfully responded, “Well, actually, we don’t have any.”
“Well, we do have enough for five patients (for one month each).”

Well, now I’m thinking five loaves. How ‘bout any fishes?

Without actually performing any miracles, Scott Will (a visiting Physician assistant) and I managed to see all the AIDS patients who needed Treatment. Every patient who needed ARVs did received them, but most only received a one week supply and some received combinations of drugs which were new to them. Not ideal medicine, by any stretch of the imagination. This means that instead of the usual one month return visit date, all these patients will be back next Wednesday, effectively doubling the size of the clinic next week. Umm, I think, I need to go to Kampala next week.

Why? Why is the drug supply like this? The supply chain has many links none of which are very strong. Responsibility can slip at the source (National Medical Stores), DELIVER (the logistics agency which handles the requisitions), the ARV Clinical Officer (who should send in a monthly request), or the Pharmacy Storekeeper (let’s not point fingers, but the temptation exists)...disorganization, inefficiency, ineptitude, apathy...any or all.

At least all of the thirty five or so patients who needed a refill of their ARVs received them. Not Mary. Mary is a 50 year old woman, skinny as a rail and patient as Job. Her CD4 count (the good white blood cells) is 48. Dangerously low. Normal is above 800. When you get below 200 it’s time to start the ARV therapy. Below 100, she is at high risk of life-threatening infections striking her at any time: meningitis, pneumonia, sepsis. As I examined her treatment card, I noticed that she has come to the clinic SIX TIMES since July 25th. Each time there is a handwritten message across the page: “Start ARVs when supplies will allow.” Each visit, the stock of drugs has been so low that only the minimum supply could be dispensed to those already started on the drugs. Not enough for any new patients to be added in. Maybe next time Mary.

The reason Dr. Jonah asked me to run the ARV clinic today is that he went (with two other staff) to a two-day training in Kyenjojo for “ARV logistics.” Learning how to manage the ARV clinic drug supplies.
So, there is hope that this situation can change.

Meanwhile, I have requested in my renewal proposal to the Elizabeth Glaser Pediatric AIDS Foundation for money to allow us to buy “back up stocks of ARVs.”

Until then, let’s pray for Mary and for this continent full of clinics with patients like her.

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