Three hours at Nohana

long read

Reaching out to the heart of the AIDS epidemic

“I just want to see how bad things are in the clinic,” Jennifer Furin said, grabbing a stethoscope from her bag and heading out the door of the small stone house perched on a Lesotho mountainside. “It’s a ‘doctor fear’ that someone is bleeding out while I’m standing here eating chocolate.”

Furin had arrived at the house just minutes earlier, long enough for a quick sip of juice and a few pieces of chocolate, a boost as her body adjusted to the clinic’s 6,000-foot altitude. A six-seater Cessna had dropped her at the site’s grass airfield scarcely 20 minutes earlier. It had touched down among soaring mountain peaks, green and brown and looking from the air as if they had been given a buzzcut by a giant razor.

Furin went down a set of steps to the clinic, passing lines of people — most of whom wore colorful hats as well as traditional blankets that provide protection against the mountain weather.

Inside, she spoke briefly with the clinic’s resident physician and director, Jonas Rigodon, a Haitian doctor who has worked for years with Furin and Partners In Health, the organization that had brought them both to this remote, spectacular place. Though a private nonprofit, Partners In Health has strong ties to Harvard Medical School’s Department of Social Medicine, Harvard School of Public Health’s Francois-Xavier Bagnoud Center for Health and Human Rights, and Brigham and Women’s Hospital’s Division of Social Medicine and Health Inequalities.

The clinic offers the only health care for miles around. It officially serves a population of 7,000 people, though its reputation draws some from much farther away. Doctors there see as many as 300 patients a day, suffering everything from minor illnesses to gunshot wounds. Things were under control, Furin learned that morning, except for a small baby, admitted hours earlier, malnourished and dehydrated.

The baby, a 15-month-old named Kazabelo, was in a small room with two beds. Light and airy, the room’s open door and windows let in a cooling breeze against the Lesotho summer heat. An old woman in a green-brimmed hat and a flower print dress sat next to a bed under the window. Kazabelo was hidden by a dark blanket that was keeping her warm and keeping the flies away. Furin raised the blanket’s folds and was immediately concerned by what she saw.

Kazabelo was emaciated, weighing less than 7 pounds and looking far too small for her age. As Furin gently lifted her, Kazabelo’s chest and abdomen heaved as she struggled for breath. Her hair was patchy, a large bald spot covered one temple. A fungus, likely Candida, had attacked her skin, creating light-colored spots on her face, nose, and body. As Furin gently unwrapped the cloth that served as a diaper she winced — Kazabelo’s rump was raw, with most of the upper layer of skin gone.

The baby’s grandmother sat silently as Furin examined Kazabelo. Furin cooed a long, soft apology as she worked: “I’m sorry, princess, I know, I know, it’s no fun to be little and sick.”

The grandmother had brought in the baby that morning, hiking four hours from Hapata, up and down the region’s rugged hills.

The hiking would have been hard, but the grandmother was used to these hills. The baby that day would have been a tragically light burden, a feather of a child holding a flicker of life and not much more. Her mother died of AIDS three months earlier and the baby’s father’s situation was unknown: dead or gone. To the grandmother had fallen the burden of caring for her daughter’s three children, including at least one perilously sick.

Kazabelo had been in the clinic a month and a half earlier and had weighed in at 13 pounds. She lost half her body weight in the intervening weeks. Furin diagnosed the baby as suffering from tuberculosis. Furin also suspected HIV, but a test had shown Kazabelo negative for the virus that took her mother’s life. Tuberculosis without HIV would be an unlikely combination in a country with the world’s third-highest HIV prevalence and in which the vast majority of TB cases are in people infected with the virus. The path of the global HIV pandemic had diverged in the developing and developed worlds, galloping ahead among the world’s poor even as antiretroviral drugs, established health-care systems, and public education campaigns have, in the world’s wealthy nations, gradually turned HIV and the AIDS it causes from a death sentence into a manageable, chronic illness.

It has been particularly ruthless in southern Africa, where the countries with the world’s highest HIV prevalence are found. In Lesotho, between one in three and one in four adults in the nation of 1.7 million are infected, and life expectancy has plummeted to 34 years. The availability of antiretroviral drugs and increasing commitments from some southern African governments have given health workers hope, but the disease has a long head start. Workers are further handicapped by the lack of facilities, electricity, and even roads in remote locations — such as the mountains that cover much of Lesotho.

The virus’ sexual transmission targets those in the prime of their lives, gutting societies of people in their most productive years, taking not only mothers and fathers, but also the aunts, uncles, teachers, and other professionals who might step in to help the children left behind.

The result is a society increasingly made up of the young and the old, like Kazabelo and her grandmother — one mourning the loss of the mother who should be protecting and nurturing, and the other suffering the tragedy of having lived long enough to bury her child.

Left behind by the youthful dead, grandparents across the region again take up the burden of parenthood at a time in their lives when they should be helpers, stepping back and enjoying the little ones. Instead, their strength failing, they take on parenthood again, only this time in the face of a terrible disease.

But at least this time there was a clinic to come to.

Partners In Health arrived in Lesotho in 2006 in the person of Furin, an instructor in medicine at Harvard Medical School, an infectious disease specialist at Harvard-affiliated Brigham and Women’s Hospital, and a longtime doctor with Partners In Health. Furin, who would become Partners In Health’s country director for Lesotho, set up a national headquarters in Lesotho’s capital of Maseru and then turned her attention to the mountainous area of Nohana, where the clinic perches.

Lesotho, through the vagaries of colonial history, is a small highland nation completely enclosed in South Africa. Peopled by the Basotho, much of the population lives on the lowland plateau — still 3,000 feet high — that makes up a third of the country.

Nohana is just one of many communities, often inaccessible by road, that dot the mountains. Furin quickly realized that air travel — by the planes and pilots of the nonprofit Mission Aviation Fellowship — would be the only way to effectively maintain supplies, communication, and emergency transport at the remote sites. Within two years, Nohana had grown from four buildings to seven, with a new clinic building ready to open within days of Kazabelo’s arrival. Nohana had been joined by four other sites in the mountains, and Furin hoped to have a total of 10 clinics open by year’s end. Countrywide, the organization had seven doctors, almost one-tenth of the total in the entire nation.

The changes over the past two years at Nohana were apparent that day. Not only were there more supplies and personnel, there were more patients as well. The clinic had seen 60 patients a day before Furin’s arrival, when it was staffed by a single nurse paid by the Ministry of Health. But after Partners In Health’s arrival, news spread that a doctor was always present and had the medicine to help. Patients came flooding in, crowding the clinic’s tiny examining rooms.

“They were just dying at home before. Now they know they can get care,” Furin said.

Furin’s work and that of other Harvard-affiliated faculty members working with her in Lesotho 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.

Furin knew that Kazabelo hovered on the edge of life and death. Furin doubted the HIV-negative test result and ordered another. Then, assisted by K.J. Seung, an instructor in medicine at Harvard Medical School visiting Nohana from the organization’s TB clinic in Maseru, Furin set to work.

In a U.S. hospital, Kazabelo would have been considered in critical condition, Furin said. She’d be in an intensive care unit, surrounded by doctors, though it is unlikely a child would be allowed to get this sick. Two years earlier, the baby almost certainly would have died, as neither the knowledge nor the equipment to save her existed at Nohana. The death would have happened quietly, however: just another African baby dying in a place so remote that she wouldn’t even have been a statistic.

There are no sure things, of course, even with good medical care. During Furin’s two years in Lesotho, she’d held more than one child as it died. She sees them again at night, when she finds it difficult to sleep, trying to figure out whether she might have done something differently.

Outside her quiet apartment in Maseru, however, Furin is a blaze of activity — a “fireball,” her friends call her. The bush pilots who fly her to remote sites — themselves intrepid heroes of a kind — speak of her energy and determination with awe. She can’t rest, really, even to eat another piece of chocolate. Somewhere someone is lying sick, possibly horribly so. In a nation with just 80 doctors, there’s no time for rest.

But that day in Nohana, the baby had a chance. For a variety of reasons, with Furin that day were three other doctors — together making up more than half of Partners In Health’s seven-doctor Lesotho workforce.

As Nohana clinic director Rigodon and a new doctor recently hired from Zimbabwe handled the stream of patients, Furin and Seung focused their attention on Kazabelo.

Getting an intravenous line in was the first and most critical order of business. Without fluids, the baby would die, possibly within hours. With tiny veins collapsed from dehydration, earlier attempts to tap veins in her arms, legs, and even scalp had failed.

Furin decided to try the left subclavian vein, a large central vessel that runs under the collarbone. It was a bigger target, but tricky to find. Talking soothingly to Kazabelo, Furin numbed the area with a shot of lidocaine. Kazabelo cried weakly and turned her head as the needle went in. After giving the anesthetic a few moments to work, Furin inserted the IV needle, guiding it beneath the collarbone by feel and an intimate knowledge of anatomy. Minutes ticked by as she probed. The baby moved only slightly despite the discomfort, her head held still by Seung.

No luck. Another try. Into the silent room drifted the sounds from outside — bits of conversation, a few notes of bird’s song from a nearby tree. Again nothing. Another attempt. Finally, Furin stopped. She had gotten the little spurts of blood in the syringe that told her she’d found the vein, but the blood flow had stopped almost as soon as it started, the needle skimming the vein’s rubbery surface.

The clock was ticking and they still needed to get an IV in. They decided to try the same vein on the other side. Furin was holding in reserve a more surefire solution, but one that she was loath to employ. The intravenous line could be placed in the baby’s shinbone — sending fluids into the marrow and from there out into the baby’s body. But doing that required a thick, stout needle and brute force to push it through the bone. It was tricky to maintain, slipping out easily, but the real issue to Furin was that it was excruciatingly painful.

She wasn’t ready to put Kazabelo through that just yet. Pulling the bed away from the wall, Furin and Seung repeated the earlier procedure on the other side. First lidocaine, then probe with the IV needle. They knew the vein was there somewhere — but so were Kazabelo’s lungs, so Furin took care to not probe too deeply. She used the collarbone as a guide, and followed it with the needle. Nothing.

She tried again, as time trickled away in the room and Kazabelo’s future hung in the balance. The room was silent but for Furin and Seung’s terse conversation and Furin’s soothing talk to Kazabelo.

“I know, sweetie, I know. … I know that it hurts and I’m sorry … I’m sorry.”

A few moments more and there was a brief flash of success as blood spurted into the syringe, then stopped as the needle slipped out again.

After 13 long minutes of trying, Furin gave up on finding a vein.

“It doesn’t want to stay; we’re going to have to go into the bone,” Furin said to Seung, then to Kazabelo, “I’m sorry, baby girl.”

With instructions to Seung to hold the baby’s leg down firmly, Furin again injected her with lidocaine and then pressed hard with the stout, tough needle. Kazabelo whimpered sofly, but a few seconds later they were in. The needle proved a bit tricky to position in the narrow space in the baby’s bone, but after a few adjustments, the IV fluid flowed steadily. Finally, they had a lifeline. Fluids flowed through the plastic tubing into the baby’s dehydrated body. Medicine would follow: large doses of two antibiotics to fight any underlying infection. Then, her cloudy eyes called for vitamin A, so Seung took a gel caplet, impossible for Kazabelo to swallow, cut off the end and squeezed the sweet liquid into her mouth.

Drugs for the tuberculosis that ravaged the baby had to be taken orally, so the next task was inserting a nasogastric tube, up through the nose and down the back of the throat into the esophagus and stomach. Kazabelo struggled a bit with that — a good sign, according to Furin. Once the tube was in, Seung crushed up medicine to fight tuberculosis, suspended it in water, and injected it in the tube. Steroids to help Kazabelo’s lungs followed.

Then Furin turned her attention to Kazabelo’s raw skin. After cleaning the baby, Furin smeared antifungal ointment on her face and rump, wherever the patches showed Candida at work. “She’s got bad, bad skin breakdown here,” Furin said, then to the baby as she dabbed. “I’m sure that’s very sore. I’m sure that’s very sore. … OK, princess. …”

By then, Furin and Seung had been working on Kazabelo for nearly two hours. The plane, returning to pick Furin up, was expected soon. The quick turnaround meant a short stay in the mountains, but gave the pilots enough time to get back to Maseru before the afternoon thunderstorms rolled in.

But the plane was late, so Furin spent the next hour checking on other patients — a man stabbed in the head and chest, a 30-year-old woman who had suddenly lost her hearing and ability to walk. The woman tested positive for HIV, and Furin diagnosed meningitis as the cause of her neurological troubles. Meningitis can be brought on by TB, which sets in as HIV ravages the immune system. In between, Furin popped in and checked on Kazabelo every few minutes, trying to get her to eat a bit of vitamin-fortified peanut butter. She also gave instructions for the staff who would care for Kazabelo in the days to come: formula first through the feeding tube, and then by mouth if possible, and medicine to fight her several ills.

With the plane more than an hour overdue, Furin finally allowed herself a rest, going to the house to sit, eat a bit, and take a drink. As she decompressed, she related Kazabelo’s case to the struggles of a nation at the epicenter of a calamity.

“I feel like if I hadn’t been here today — if our team hadn’t been here today, this child would have died,” Furin said. “I took care of a baby who otherwise would have been ignored and who didn’t become just another dead African baby.

“It’s a mess, it’s just a big fat mess,” she said of the complex interaction of AIDS, TB, and poverty in Lesotho. “It’s a mess every day, but it’s better than it was, so we’ll just keep trying.”