Home Visit

Today I went out on home visits. The first place we went to involved a boda boda ride over dirt paths for over half an hour (and believe me these are not bikes equipped with shock absorbers!) - I was just glad I managed to stay on. As we passed from the inner city slums to the more open areas, I was greeted by cries of "Mzungu!" (the term for a white person) by the many children who went into fits of giggles when I waved back. Outside of my apartment complex, I have seen one other white person since being here so I guess my appearance in the back roads of Kisumu is a bit of an event.

We arrived in the mud-walled hut (dung, too I'm guessing by the smell!) to visit one of the clinic patients who was unable to walk. Just sorting out what is going on is an incredible challenge - there are so few tests they can run compared to what we are used to. Much of diagnosis is based on probability and "treat and see". For example this woman had undergone treatment for toxoplasmosis and TB meningitis both with no response so now we were left pondering what else it could be. What about CMV (a viral infection that can cause blindness - which this woman also had)? An opthalmology exam a month ago hadn't shown anything and, regardless, there is no way the woman's family would be able to pay for the expensive treatment of IV antivirals. A lumbar puncture (or spinal tap) was done but it can only be sent for a limited number of tests (total protein and cell count and CrAg for all you medical types). It could be lymphoma of the brain or PML (another virus that causes weakness in advanced AIDS), but without a CT scan (which the family would have to pay for), how could we be sure?

Just one month prior, I had a similar patient who was brought into the ED by his family. Between MRI's, PCR of his cerebrospinal fluid, special cultures for various viruses, we had no trouble arriving at a diagnosis - and paying for three weeks of expensive anti-viral therapy.

This woman would have no such luck. In the end, we hoped it was something we could cure - or at least help - by putting her on anti-retrovirals and building up her immune system. There are programs to be sure she has food - if the family can make the long trip in to pick it up. The clinic will be sure she gets her medicine - and hopefully there will be someone who can stay home from work to give it to her.

But somehow, in the midst of being confronted over and over again with what we could not do, the fact that we were there at all and able to offer the patient and her family something to combat her inevitable decline was actually reassuring and fulfilling. Because how many patients like her die alone and far from any care at all?