A pandemic's front lines
Harvard faculty help transform health care landscape
Jim Yong Kim walked out of the small cinder block room where an underweight boy of 5 lay, his heart rate down to 115 from the dangerous 150 beats per minute at which it had been racing moments earlier. Kim stripped rubber gloves from his hands.
"That was incredibly gutsy," he said flatly, looking around the bare anteroom and out the open door that led to the mountain clinic's other buildings. "I'm glad Jen was well-trained."
Jen is Harvard Instructor in Medicine Jennifer Furin, an infectious disease specialist at Harvard-affiliated Brigham and Women's Hospital and a physician with the Boston-based nonprofit Partners In Health.
She and Kim, professor of social medicine at Harvard Medical School and the François-Xavier Bagnoud Professor of Health and Human Rights at the Harvard School of Public Health, had arrived just 40 minutes earlier at this clinic in Bobete, Lesotho, high in the African nation's remote mountains. Knowing they had just a couple of hours at the clinic, they had gotten right to work. Furin asked the staff whether there was anyone "sick sick" - seriously ill who needed her attention.
They led her to a small, cinder block building, with a few tiny rooms off the entrance hallway. In one, a boy lay on a thin mattress on the concrete floor, his mother sitting in a corner nearby. His labored breathing - hnnnn-a, hnnnn-a, hnnnn-a - could be heard as soon as one entered the building.
Furin quickly reviewed the boy's records. He was 5 years old and severely malnourished, weighing just 22 pounds. His father had been killed in a violent attack years earlier. The boy had come in two days before, breathing poorly, probably from pneumonia or tuberculosis, which is widespread in the region.
The more Furin examined the boy, the more worried she became, noticing a visible pulse high in his jugular vein. She finally looked up at Kim, who stood leaning over her. "I'm worried about pericardial TB."
The bacteria that causes tuberculosis sometimes doesn't limit its attack to the lungs, as it does in classic cases of the disease. Sometimes it spreads to other parts of the body, including the membrane sac that encloses the heart, called the pericardium. If that sac becomes infected, it can fill with fluid, constricting the heart's ability to beat and causing a rapid, shallow heart rate as the organ struggles to pump blood around the body.
The diagnosis clearly concerned Kim, as did the recommended course of action: insert a needle into the pericardium and withdraw the fluid that was throttling the heart. Kim told Furin that the procedure was done only a handful of times a year at the Brigham; pericardial TB is a relatively rare condition in the United States.
The situation is different in Lesotho, however, caught between the grinding jaws of twin epidemics of HIV and TB.
"I've done 50 of them," Furin said.
Though they didn't like the diagnosis, the facts remained unchanged. In any major children's hospital in the world, this child would be the sickest there. He would be attended by a team of physicians, including a cardiologist who would perform the procedure in a sterile operating room, guided by ultrasound imaging equipment to ensure the needle didn't nick the heart or another vital organ.
"If it was at all possible not to do this, we would not do it," Kim said. "He could die pretty quickly."
Furin left the room and returned a few moments later with a fistful of latex gloves in one hand and a large syringe, swabs, and other supplies in the other. She squatted again and carefully tapped the boy's chest to find the spot where she thought the needle should go in. Then she swabbed and numbed the area with a local anesthetic.
"I don't want to hurt you, but we need to give it a try," Furin said gently to the boy, whose labored breathing continued unchanged and who showed no sign of having heard her. Then she carefully inserted the large needle into the spot on his chest she had marked seconds earlier. The boy's breathing rose to a cry as she moved the needle slightly to find her target. A moment later, she pulled back on the syringe, drawing 15 cc of bloody fluid into the large tube.
She pulled out the needle and held a gauze pad over the tiny hole she had made. Nobody in the room moved as Furin examined the fluid. She noted how watery it was, assuring herself and onlookers that it was not blood. Within seconds, the boy's heart rate dropped, falling from 150 to 115 and stabilizing there. He lay quieter as Furin gave further instructions to the clinic's head nurse. Then she and Kim headed outside to breathe the thin, crisp air at the clinic's 7,100-foot altitude.
Rugged mountains and plunging valleys are visible from any spot in Bobete's compound. The surrounding hills are full of people just like the boy Furin and Kim treated: impoverished, malnourished, and stricken with a variety of ills. The poverty that has existed in this part of the world for centuries prepared the ground well for the spread of AIDS that has taken place over the past two decades. More recently, tuberculosis has emerged as a deadly companion to HIV, the virus that causes AIDS and ravages the immune system, opening the body up to attack by other diseases.
Across southern Africa, the twin epidemics feed off each other, consuming their victims' bodies and leaving behind emaciated wrecks and, in many cases, death.
The AIDS epidemic may seem like yesterday's news in the United States, where infection rates have leveled off and a new generation of drugs have converted it from a death sentence into a manageable, long-term condition. But in Africa, the epidemic was allowed to spread while international experts said the lack of hospitals, clinics, doctors, and nurses meant they couldn't use the new revolutionary drugs that keep the virus in check.
Partly due to Kim's efforts and proof provided by Partners In Health's programs, international health experts have changed their minds. Today, the drugs are being employed in poor countries as well as rich ones. At the Bobete clinic alone, 3,000 people have been tested for HIV over the past two years, and 500 have been started on antiretroviral therapy.
But the epidemic has a long head start. In Lesotho, as in the rest of southern Africa, the death sentence from AIDS has yet to be commuted to life, as it has in the United States. And the leading executioner is tuberculosis, which ranks first as a cause of death among HIV patients in Africa.
Furin has been engaged in the battle against disease in Lesotho since she arrived two years ago as Partners In Health's point person. After negotiations with the Lesotho government, the Boston-based nonprofit, which has close ties to Harvard Medical School, the Harvard School of Public Health, and Brigham and Women's Hospital, agreed to take over a group of failing government-run clinics in the nation's mountains. The plan was to revamp, restaff, and resupply the clinics, installing Partners In Health's community-based care model along the way.
The work of Furin and Kim is an example of an enormous and diverse body of global health research, education, and training across Harvard. Researchers toil away to understand everything from the genetic code of the malaria parasite to the impact of air quality on human health, instructors impart the latest in medical knowledge to top students, and colleagues at Harvard's many affiliated institutions not only teach and conduct research of their own, they also put that knowledge into action to improve people's lives - in Boston and around the globe.
Lesotho has one of the world's highest HIV infection rates, estimated at nearly 25 percent. Unlike many other countries where rates are high in the cities and lower in the surrounding countryside, in Lesotho, one in four adults are infected pretty much everywhere. Among 15- to 17-year-old girls, the impact is even greater, with an estimated 46 percent infected with HIV.
The epidemic has already taken a toll. Life expectancy in the tiny nation, completely enclosed by South Africa, has fallen to 34 years. Because the disease strikes mainly those in their sexually active years, it removes society's most productive people, leaving behind a population disproportionately made up of the young and the old.
One consequence is an explosion of children who've lost one or both parents. The nonprofit Catholic Relief Services worked with Partners In Health to help orphans in the Bobete area, estimating they'd find as many as 2,000 in the 50 villages Bobete serves. Once the survey began, however, they found 2,000 orphans in just the first 30 villages, making them realize that even their dark projections had been optimistic.
But things are changing in Lesotho. By January 2008, Furin's team - working closely with the Ministry of Health - had begun offering antiretroviral drug therapy and improved health services at five mountain clinics, with plans for Partners In Health to begin operations at another five during 2008. Teams of paid community health workers have fanned out in the countryside, checking on patients daily and making sure they take their medicines. As a result, the default rate of patients on medication for HIV is less than 2 percent, Furin said. Another result is that patients, who trickled into the clinics before Partners In Health arrived, have come flooding in.
"We see more sick people than ever before," Furin said. "Does that mean Lesotho is getting sicker? On a bad day, when I'm crying my eyes out, yes. But [what it probably means] is that they were just dying at home before and now they know they can get care."
Furin also helped the government revamp its tuberculosis laboratory at Queen Elizabeth II Hospital in Lesotho's capital city of Maseru. She oversaw efforts to renovate a former leper hospital on Maseru's outskirts into a state-of-the-art facility for multi-drug-resistant tuberculosis. She also built the organization's staff along the way. By early 2008, Partners In Health employed seven doctors in Lesotho, nearly a tenth of the nation's total, and planned to add more as new clinics open.
"Jen as a single person, and her team, have transformed health care in Lesotho. The minister of health told us that," Kim said. "The speed with which Jen built the program . got us a lot of credibility. We've done better, faster than we could ever have imagined."
But Furin realizes that the progress isn't nearly enough. Ten clinics in a nation of 1.7 million where one in four adults is infected with HIV won't begin to stem the epidemic. Partners In Health selected the initial 10 clinics because they were located near rudimentary grass and dirt airfields and could be serviced by air. Furin said in January that once those clinics are up and running, they'll expand to clinics that are near closed airfields that can be repaired and reopened. After that, she said, they'll have to figure out how to reach clinics with no place for a plane to land. In all, Furin estimated that 50 clinics will be needed just to fight the epidemic to a standstill. And there's not much time.
"We're sitting in the epicenter of the disease, so we have to work quickly," Furin said. "We don't have 20 years to make this right. In 20 years it'll be game over. We'll be sitting around talking about the time we were in Lesotho, that country that doesn't exist anymore."
Furin, Kim said, embodies the attributes needed to do this kind of work well. She's not only highly skilled, energetic, and dedicated, she's imaginative too. When she first arrived in Lesotho and was sorting out the logistics behind the first clinic at Nohana, it became obvious that the mountain roads' terrible condition would be an obstacle to keeping the clinic supplied, getting staff in and out, and transporting severely ill patients in need of more advanced care.
Luckily for Furin, a solution she never imagined was flying overhead. Mission Aviation Fellowship, a Christian nonprofit organization whose aim is to provide air service to places where it is needed, was running operations out of a small airfield in Maseru.
Working with the government-run Lesotho Flying Doctors, Mission Aviation Fellowship made a few flights a week to remote medical facilities around the country. Seeing an opportunity, Furin quickly began booking flights. Mission Aviation Fellowship's tiny six-seater Cessnas quickly became a vital lifeline between the remote clinics and Maseru, ferrying people and supplies and cutting travel time from eight hours overland to less than an hour.
The two operations quickly came to rely on each other. As Partners In Health's needs have grown, the fellowship's work has expanded. From three aircraft and four pilots, they've grown to five aircraft and eight pilots, with plans to bring in two more aircraft to support Partners In Health's expected expansion.
Though not physicians, the pilots' essential role has thrust them into the medical battle being waged across the tiny nation. They operate not just as a flying taxi service, but also as a freight service, ferrying needed supplies; as an ambulance, flying seriously ill patients; and sometimes as a hearse.
While waiting for the morning flight to Bobete and the boy with pericardial TB, Kim and Furin's flight was delayed so that pilot Melvin Peters could be diverted to a government hospital to pick up a seriously ill patient.
As Furin, Kim, and others waited at the airfield, Peters picked up the patient and headed to Maseru where the man could receive more-intensive treatment at the government-run hospital.
The effort was too late, however. Just 42, the man died minutes from the airport, triggering a desperate scene on landing to revive him. Furin, Kim, and the fellowship's pilots hurriedly carried the man out of the six-seater and into a small brick building where Partners In Health had set up a lab. For 10 minutes, they attempted to revive him, an effort that was ultimately unsuccessful.
There was little time for mourning, however. More patients waited in Bobete. While Furin consoled the man's relatives, Mission Aviation Fellowship staff stowed Furin and Kim's bags on the plane for the next flight. Peters, shaken but calm, climbed in and, once his passengers were aboard, taxied the plane for takeoff.
Mission Aviation Fellowship Program Manager Mike Shutts said death is part of the reality of the work his pilots do. Barely a week passes that they don't fly a body as part of their cargo.
"One thing we don't like flying is coffins. [But] just about every week, we'll fly somebody back," Shutts said.
Shutts said his pilots have been impressed with the dedication of Furin and her team. When they get an emergency call, if Furin is around, she'll fly out with them, even in the middle of the night. That allows her to provide care that sometimes makes the difference between life and death. It also causes Shutts and other pilots to shake their heads in admiration.
"I don't know how she does it, she works too hard," Shutts said. "The first time we heard that doctors from Harvard were going to be going out and staying there [in the mountains], we thought, 'No way.' We've been impressed with their tenacity."
The admiration goes both ways. Furin repeatedly sings the praises of the organization's pilots and says Partners In Health wouldn't be able to operate in Lesotho without them. The pilots fly several times daily between Maseru and the mountains, landing on dirt and grass airstrips amid the thunderstorms and snow that are part of unpredictable mountain weather.
Another unexpected development, Furin said, was the need to establish their own laboratory at the airfield. In the small brick building where Furin, Kim, and the pilots worked on the man who had died inflight are several key machines to conduct a variety of medical tests. Furin said they decided to open the lab after samples sent to the government lab at Queen Elizabeth II Hospital were too slow coming back.
"If you'd asked me a year ago whether we'd have a small lab at an airplane hangar, I'd have said no," Furin said. Then, referring to the need to handle emergencies in the building as well, "We've had some dark moments in that little room back there."
Though progress is being made, Kim said there's lots of work to be done in Lesotho. But as bad as things are there, the nation is ahead of other countries with similarly high HIV infection rates that have yet to take even Lesotho's initial steps.
"We're still at the stage of mopping up years of neglect and malnutrition in this place," Kim said. "We'll be treating for a long time the misery that has existed here for [many years]. We're dealing with some of the sickest people I've ever seen."