Monday, May 07, 2007

The battlefield – Introducing Alshande (4 of 10)


War is a powerful metaphor, especially in places that have been surrounded by it. Swaziland has enjoyed relative peace compared to its neighbors, but the Swazi flag features a large oblong shield, and traditional Swazi attire includes a knobkerrie, a type of wooden club that doubles as a walking stick and bludgeon.

Because nearly everybody understands war, we use it frequently to explain the physiology of HIV.

When discussing the immune system with patients, we call the CD4 cells “soldier cells”, explaining that they fight the many germs that try to invade the body. Once the patient is comfortable with this analogy, I usually add that CD4’s are actually much like the generals in the army, as their primary job is to tell other immune cells how to kill the enemy. I then explain that HIV specifically attacks and destroys these important commanders, and so the immune system’s forces are weakened.

When it comes time to discuss ARVs, I explain that they work by protecting the soldier cells from the attacking virus, so the soldiers and the army can become strong again.


The Mozambican Civil War was only three decades ago, and it was not a war of leather shields and wooden weapons. It was fought with sprays of bullets, grenades, land mines, and other devices designed to penetrate flesh, be it Mozambican or Portuguese, black or white, correct or incorrect.

Over five million Mozambican civilians were displaced and 900,000 are thought to have died in fighting and from starvation.

The fighting started in Mozambique following independence in 1975. The ruling party, the Front for Liberation of Mozambique (Frelimo), was violently opposed beginning in 1977 by the Rhodesian- and later South African-funded Mozambique Resistance Movement (Renamo).
Fighting finally ended in 1992 and the country's first free elections were held in 1994.


Alshande, pictured above, was born in Swaziland seven years later to a mother who had fled the war. He was infected with HIV during birth, and when he came to us late last year, his CD4 count was 38.

Normal for five year-olds is at least 500.

If an immune system is a suit of armor, Alshande is wearing tin foil, and not the expensive, heavy-duty kind, but the cheap kind that tears too easily as you pull it out of the box.

I always ask Alshande’s mom to request me as their doc when they register at the clinic. There are two reasons for this. One, it is nice to watch the child get healthier and heavier. (He has gained three kilograms since first coming to our clinic.) Two, I enjoy speaking Portuguese, and his mother speaks little else.

Alshande arrived to our clinic with a hemoglobin of 7. This means that he was getting by with approximately half of the red blood cells of healthy five year-old, likely a result of inadequate iron intake and the long-term stress that chronic illness places on the body. (While anemia could potentially fit into the war metaphor, I usually refer to the blood being “too thin”, which works well because the Swazi diet consists largely of thin corn starch porridge. Since thin, watered down porridge is understood to be inferior to the thicker, heartier version, it follows that thin blood needs thickening.)

Two months ago, Alshande was started on iron and ARVs, and next month we will repeat his blood tests and see how his red blood cells and soldier cells are responding to treatment.


HIV will never retreat entirely from Alshande’s body. We do not yet know how to definitively defeat the virus. Our goal with ARVs is to force the bad guys into hiding so the soldier cells can replenish their numbers and go about their business of protecting the body from everyday microscopic threats.

That itself is a sizeable mission, especially in places with limited clean water and hygiene facilities.

The human body, if permitted to discreetly conduct the day-to-day battle against Nature’s intruding pathogens, mercifully graces us with the perception of health, strength, and sometimes even inner peace.

Judging from the above photo, Alshande has the potential to achieve all three.



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