The work at Ward 1C had become routine—or at least that was the way I saw the final days of my internship in Pediatrics in March 2002. It was a grueling six months at Uganda's National Referral Hospital in Kampala. We were only two interns covering both the in-patient and the emergency wards. Despite the busy schedule, certain patients remain etched in my memory forever.
Abraham was under my care. (I have changed his name for confidentiality reasons.) He was 4 months old. His grandmother looked after him. He came to the emergency unit with high fevers and convulsions. When the pair first walked in, we were struck by his shrill cries and his lapses of consciousness. After he was diagnosed with meningitis, we started him on intravenous antibiotics. Over the next few days the fever went down, the convulsions stopped, but he continued crying.
When he became an in-patient, I had more time with the grandmother and asked her why she was caring for Abraham. She told me that his mother died from TB when he was three weeks old; she was not sure about the father. The grandmother's other two daughters and her son had died from AIDS. I inquired whether she thought Abraham's mother had died from AIDS as well. She nodded and said it was obvious—all her children had died while coughing. Her profound numbness in answering these questions showed me that she had long passed her threshold of pain. She was taking care of four other orphaned grandchildren.
I asked her what she did for a living. She told me that she carried water from the central tap to the houses of other people. At her age, she was doing this hard work to stay alive. I wondered where she would leave Abraham as she did her work. She shrugged and said, "On the roadside. No one will steal such a child."
As I was leaving one day, she asked if we could give Abraham the full two-week course of intravenous antibiotics needed for his meningitis. At the hospital, we never had enough medication, especially expensive intravenous antibiotics. We could manage to give the first few doses but not the maintenance doses. The nurses had already pushed it for five days. Now, she had to buy. I said I would see what we could do.
Abraham started crying again, and the grandmother worked desperately to calm him. I tried to figure out what was causing him to cry. He had no clothes, only a shroud of polyester material—clearly a piece of an old dress. He was emaciated and seemed to be in pain. He could not stretch his arms any more. Although he cried incessantly, he had no tears. Abraham was dehydrated, despite having a continuous infusion drip. He had persistent diarrhea.
Over the next few days, it was a struggle to get Abraham the medications. Sometimes we would go to the other wards, sweet talk the chief nurses and ask for a vial of antibiotics as we bid farewell. But the nurses got to know our trick. When they saw us approaching, they would announce that they had nothing to spare. By raising money amongst ourselves and mothers in the ward, we managed to give him 10 days of antibiotics.
Abraham progressed very slowly. He suffered from protein energy malnutrition (also known as Marasmus). Children with Marasmus characteristically have increased appetite and will cling to the milk cups and drink until they are out of breath. Sometimes Abraham wanted to drink but could not because of the raw sores in his mouth and throat.
We did an HIV test that turned out to be positive. His grandmother was not surprised. Over the next few weeks, Abraham improved neurologically but then had bouts of diarrhea and malaria. It was a struggle to treat him considering the underlying HIV and the fact that we had no antiretrovirals. We were only treating his symptoms.
He passed away five weeks after his admission to the hospital.
Abraham's story is one that we see every day at hospitals in the developing world. Yet few even make it to a hospital. How many other children like Abraham were left on the roadside? With antiretroviral drugs, Abraham may have lived a little longer. But without food, clothing or proper social support, how long would that improvement be sustained?
Poverty and disease are twin brothers. Identical, I suppose. It is futile to treat disease if we do nothing for the underlying cause. Though it is simple to state epidemiologic terms like "prevalence" and "incidence of disease," we must realize that behind these statistics are people—people with the gift of life, with families and people who care for them, who want to live and not just to exist.
Policy issues in HIV care should be geared not only toward the provision of drugs, but the alleviation of the underlying promoter: poverty. How many more children must die or be orphaned before we open our minds, our hearts and our wallets?