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Published: March 9th 2010
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My work From February of 2009 to February of 2010 I worked for MSF France Kenya at a clinic called Blue House. It is located in the Mathare slums of Nairobi where possibly as many as 250,000 - 500,000 people live in an area of a few square miles (tens of square kilometers).
As you might imagine and by looking at the photos, living conditions are exceedingly difficult. Housing is very crowded and there is no running water (people purchase water 20 liters - 5 gallons - at a time and carry it home).
Sanitation is found in communal toilets for those with money to pay (1 toilet for every 400 people), or families walk to the top of the hill above the slum and squat (so you can imagine what’s in the runoff from the rains). It’s a dangerous place in many ways - the last fire displaced 80 families - with crime and disease, drugs and plenty of alcohol. Changaa, the local brew, is cooked in 55-gallon drums and condensed in hose pipes set in the (very polluted) Mathare River which runs through the middle of the slum. Drunks are all over the place. What a
waste.
Despite the challenges, most patients arrive on time for their appointments at Blue House, washed and with clean clothing.
Blue House provides care for 2800 + patients with HIV/AIDS and another 220+ with regular (not drug resistant) TB. The majority of our TB patients are co-infected with both diseases. This is because most people in the slums (and throughout most of the world outside North America and Europe) have been exposed to TB at some point and harbor the bacillus somewhere, usually walled off in the lung (this is called latent TB). When the immune system is weakened by HIV/AIDS or something else, the bacilli ‘escape’ and cause active disease. For people with latent TB who are HIV negative, the annual risk of getting active TB is 2 of 1000. But for those with HIV, the risk is 78 of 1000, so at the end of 10 years almost all of them will have active TB.
I was the TB doctor at Blue House. My responsibilities included working with the clinical officer (like a physician assistant) seeing the regular TB patients (we follow between 200 and 250 active patients who get treatment from 6 to 9
months), providing consultations for complex cases and making improvements as needed in the system. We provide a ‘one-stop shop’ approach, so patients with both TB and HIV get treatment for both until they complete their TB treatment. Then they go back to the ‘HIV side’ to continue their HIV care.
I also provided the majority of the care for our group of multi-drug resistant TB (MDR-TB) patients who come 6 days a week to take their medications for 21-24 months at Blue House 2, a separate building specifically for MDR treatment. At Blue House 2 we had 19 MDR patients when I left, having ‘graduated’ 2 in June 2 in July, and one each in October, November and December, with much celebration. We are adding more every month - the program has gone from 10 patients when I arrived to 19 with 3 more scheduled to start just after I left. The protocol for treatment and the program provided by MSF has been very effective, and we are really saving lives. One of my patients is from Uganda, where there is no treatment available for MDR TB. He reported that 4 months after coming to get treatment here, he
learned of 12 people at the clinic he came from in Uganda who had died of their MDR TB.
MDR-TB most often occurs when people have not taken their regular TB medications for the whole course or they don’t take them every day, and the few bacilli that are resistant to the 2 most effective medicines we have for TB are allowed to grow. We have a growing number of patients who are refugees from Somalia, where there is essentially no functioning government. The patients often were willing to take their TB medicines, but they go to the clinic to pick it up and the clinic has been blown up, or the staff has run away under threat from rebels, or the medications couldn’t be delivered because they couldn’t get past customs or roadblock by rebels looking for bribes, or the patients have to flee the violence there. To make matters worse, in Somalia, Ethiopia and the Sudan, people can walk into any pharmacy (chemist) when they have respiratory symptoms and will be given anti-TB medications for only 1 or 2 weeks. So anyone who develops active TB is likely to have MDR, even the first time they get
the active disease. That was the situation for one of our patients, a 20-year-old Somali man who weighed 32 kg (~ 68 lbs) and looked like a concentration camp victim. He was improperly treated in Somalia with too short a course the first time, the wrong medicines for too short a time a second time, and the right drugs but only for 2 months he next time, before he fled to Kenya. We did our best to help him. His TB was quite resistant. Not only was it resistant to the first-line, usual drugs for TB treatment, but also to one of the second-line drugs we use to treat MDR. Unfortunately, the patient got too lonely being alone without family or friends in Nairobi, so decided to travel to the Somali refugee camp in NE Kenya. There, the International Rescue Committee (IRC) put him in isolation in a hospital and we sent his medications up there to him. He and is his family were waiting for the UNHCR to register him, his brother (who was being treated for TB but probably also had MDR and who died), and his sister and her small child so they could transport all of
them back to Nairobi and we could continue his treatment here. Sadly, the family never got registered and didn’t have ration cards making them eligible for food assistance. They decided to return to Somalia, and it is unlikely that our patient survived for long without his medications.]
Our results have been very good, though. All of the patients in treatment as I leave turned smear negative by the end of the second month of treatment, a very good sign. So they are all likely to survive and go one to lead productive lives, once they complete their treatment.
My mission here in Kenya has been rewarding, challenging and fulfilling, and I look forward to doing another MSF mission in the near future. I will be back in the US in mid-February, and plan to be around for at least 2 months before I take off again. Keep in touch. I hope all of you, my friends and colleagues, are well and will enjoy a safe and prosperous new year.
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