Friday, November 03, 2006

Sticks and leaves – A patient encounter

To be seen promptly in our busy clinic, it is advisable to arrive before 7am. This ensures a quick registration so that one can pass through nursing triage, phlebotomy, adherence measurement and counseling, physician consultation, and pharmacy without one’s chart ending up at the bottom of a tall stack.

Zinhle arrived at 6:30am, and was my first patient on a busy Tuesday morning.

Zinhle had been living with HIV for eight years when I met her. She wore a ribbed off-white turtleneck sweater with a finger painting on it. The center of the finger painting was dominated by a small hand print. The purple paint was beaded and faded. The sweater was otherwise immaculate.

“Where did you come from today?”

“Siteki” was her answer after the question had been interpreted.

Siteki is a town east of Swaziland’s capital, Mbabane, near the border of Mozambique.

“How long does that take by minibus?”

“Three hours.”

“Wow, that’s far.”

“Yes, very far.”

“Did you make the sweater?”

“Yes, I painted it.”

“When did you make it?”

“This year in school.”

“I like it,” I responded, and indeed I did. Judging from the warm breeze entering the exam room window, it was going to be a very hot day, so Zinhle must have also liked the sweater to wear it on such a day. Perhaps she simply had no alternative.

I would have praised her personalized sweater further, but the glances from my coworker suggested that she would much rather be interpreting questions that would move us closer to ending the patient visit, questions of the medical variety.

I promised myself that, during lunch, I would explain to my coworker that, when an HIV positive ten year old wakes in the middle of the night to attend an appointment by herself, there is no such thing as a non-medical question.

However, lunch was five hours and many patients away.

As is my habit with a new patient, I quickly flipped through Zinhle’s chart. At the top of each encounter form there is a blank to put in the name of each pediatric patient’s caregiver. In this patient’s chart, each of these blanks was filled with the word “self”.

Zinhle was placed on ARVs just before her tenth birthday. At that time, her CD4 count was 27, with a percentage of 4.2%. If a healthy immune system can be compared to a suit of armor, this girl was immunologically naked, vulnerable to any ill-meaning predator, the slightest whiff of the wrong germ.

I turned the page and, with a jolt, learned that this was not the first time Zinhle had been naked and vulnerable. When she was two years old, she was sexually assaulted.

I read the social worker’s note outlining the rank circumstances surrounding this predatory encounter, and took a deep breath to quell the fury and dull nausea that accompany such reading.

The last line of the note states, “Patient denies any recollection or problems.”

This is not surprising. The human brain forgets, suppresses, and leaks memories, and does so strategically. Otherwise, we would have entirely too much on our mind. Important memories would be crowded by memories of your favorite preschool snack, outdated phone numbers and such. These matters are not important when compared to remembering where you parked your car or, say, the difference between scorpion and a puppy.

Remembering you were raped when you where a toddler would be the cruelest of memories, a most burdensome recollection.

I was thankful that Zinhle did not remember, but aware that she did not escape her assault without a cruel burden.

She was a 10 year-old infected with a rapist’s HIV, and she had recently developed AIDS.


When I was ten years old, I was in 5th grade at Mayes Elementary School.

My surviving recollections from that time are as follows:

If I woke up at 3am, it was to ask my parents for a glass of warm milk, or to excitedly reorganize my elaborate Garfield stuffed animal collection.

I was never by myself.

I was never raped.

I took no medicines, except an occasional Flintstone vitamin.

I never had open sores on my legs, herpetic lesions covering my face, or a persistent cough that brought with it teaspoons of mucous.

I had other concerns, though.

There was a girl named Gwen, and on one particular day we were swinging on the playground swingset and another boy, Jason, came and began swinging with us. He was a good swinger, and not only was able to swing higher than me, but also was able to maneuver his swing so that it was in perfect synchrony with Gwen’s. Gwen liked that, and I liked Gwen, and after that I was no longer liked Jason.

I could run very fast in fifth grade, as I remember it. I attributed this to my very fast shoes. I will not go too deeply into this except to say that I was the fastest kid at Mayes Elementary, a title that I was forced to share with two cooler kids, Joel and Zack. I also recall finishing in sixth place (of six) in the elementary school track meet 75-yard dash, which I thought made me the sixth fastest kid in my home town. I solemnly accepted the 6th place ribbon, marking perhaps my proudest day as a Mayes Elementary School Mustang.

When I was Zinhle’s age, I owned many hand-painted sweatshirts, all of which I had created with my mother’s assistance. I was especially fond of the one with mountains painted on it. It was red and on one of the painted mountains my mom had helped me paint a little snow skier. He was going very fast down the steepest slope of the painted mountain. (I fancied myself not only a very fast runner, but also a capable high-speed skier.) I wore these homemade sweatshirts, weather permitting, well into fifth grade, when I was taught by my peers (Joel, Zack, et al.) that they were not actually cool.

When I was ten years old, my sister was six years old, and my brother three, almost four. Our favorite activities were jumping on our trampoline and sliding down our staircase in an old, red, vinyl-coated sleeping bag. On those days when we felt more adventurous, we would walk though the woods, digging holes and then covering them with sticks and leaves so that the ground above seemed uninterrupted. We called the disguised hazards “traps.”

We tirelessly dug these holes, and thought little of why we were digging or what we could possibly hope to trap 10 inches below the forest floor. We also thought little of the potential consequences of our actions.

I must say, however, that we were very good at arranging the groundcover so that the forest floor appeared innocent, untouched. We even took pride in forgetting where the actual holes were, and failed to institute a system to ensure that we did not ourselves succumb to the traps.

It was for this reason that, one evening at dusk, my best friend from next door—Brandon—fell over the front handlebars of his BMX bike while riding a trail through the woods a few meters in from of me. He did a somersault, landing on the back of is head. I remember him lying still among the shadows of the aged oak trees surrounding our house. After a few eternal seconds, he struggled to his feet in the waning daylight.

There was less digging after that.

When I was ten years old, my parents both had full-time jobs. Still, dinner was almost always enjoyed with all five of us around our dining table. We always said “grace.” My favorite went like this: “God is great, god is good, let him thank us for our food. Amen.” I usually pronounced the word food as if I were saying “hood” but with an “f”, as the rhyme was more pleasing to my ears. I sometimes solved this problem by switching the verse around ("God is good, god is great...), which of course meant that I had to substitute the word “plate” for “food.” It was in this way that I blessed my food until the summer after my fifth grade year, when I learned a more complicated grace at summer camp, a rhyme that could be spoken or put to music.

My 5th grade math teacher was named Mrs. Ladd. She had a tall, beehive haircut and a deep, velvety voice, except when she was angry, when it approximated steel wool. Mrs. Ladd liked me, for I sat in front and rarely spoke out of turn. You see, I was an somewhat awkward child with little gift for grade school politics. My rung on the political ladder in Mrs. Ladd’s classroom was therefore low, and so I had little to lose by being an attentive student, which among pre-middle school voters in my public school district amounts to political suicide.

After I had attended to whatever lesson plan had sprung from Mrs. Ladd’s accentuated and well-meaning head, she would offer me extra credit to count from one to one-thousand (in writing). Once those numbers were meticulously submitted, she encouraged me to keep going. And so I counted, whiling away class time. Though I never reached six figures, I was able to score 284% in 5th grade math.

Of course, my 284% did not woo Gwen and therefore the time spent counting, in retrospect, seems lost. I should have been trying to decrease my 75-yard dash time or practicing my swing set cadence.


“What is your favorite subject in school?” I asked Zinhle, flashing a knowing glance in the direction of the interpreter, who smiled and translated my "non-medical" question.

“Adding and subtracting” was the interpreted response.

In May, 2006, five months prior to this patient encounter and just after starting HIV treatment, Zinhle was not doing well in school.

“Still going to school. Not doing well,” were the words scrawled on the doctor’s note from that time.

In more recent visits, it was noted that she was doing much better.

I examined Zinhle, and all was normal. No sores, no cough. These went away with the HIV medicines, which she took religiously using her own alarm clock.

“Do you feel better than when you were nine years old, Zinhle?”

“Mmmm,” she said, which in Swaziland is often given as an affirmative response. I liked her answer as it required no translation.

“Today, we are going take a small blood sample to see if your immune system is stronger now. It seems to be, for you are protecting yourself from the sicknesses you used to have…Do you think you are stronger?”


“Here is your prescription and return appointment. Ask your mom if she can come in next time. Ok?”


She bent her knees slightly as she accepted the papers—once for her prescription, and once for her appointment card.

Though I do not commonly courtesy, my knees sank, returning the gesture.

The burdened ten year-old with the painted sweater walked to get her blood drawn and refill her antiretroviral medications.

An hour later, between patients, I spoke to the interpreter briefly about the inseparability of medical problems and social context. The interpreter, who is HIV positive herself, understood immediately.

Before picking up the next chart, I looked around to make sure Zinhle had left the clinic. I hoped that she would arrive home before dark. Posted by Picasa



At 1:57 AM, Anonymous Dan Mudrick said...

Beautiful Ryan. Thanks for the updates and the inspiration. I wish you, and your patients, the best.

At 3:36 AM, Anonymous Annette, Ho Chi Minh City said...

There are so many international governmental agencies saying the same things - we have to treat kids, we have to protect orphans and vulnerable children. But the real numbers have yet to change. It is the efforts of individual programs, such as yours in Swazi, that will make the small differences that will add up. It is up to the people on the front lines to focus on the individual child to ensure that those treatment numbers represent the chance for long-lasting changes. Thanks for sharing this and for seeing beyond the labs and pill counts.

At 8:47 AM, Blogger Ryan said...

The front lines seem to be where the action is, no matter what kind of war. We need to ensure that labs and pills keep reaching the hard-to-reach individual children. This is what BIPAI is all about.

At 10:16 PM, Anonymous Joel Looney said...

Holy Smokes Ice...quite possibly the most important piece of literature I have read in 32 years. I really admire you and all the work you are doing in an effort to help those less fortunate than we are. Good luck over there and let me know the best way to contribute.


At 10:49 PM, Anonymous wml said...

Truly remarkable. Keep up the good work and I will make sure that Joel and Zack read that they were hero figures. By the way, Joel still puffs his chest at knowing you - as do I - his older brother.



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