A Death

Aissa, the younger sister of my good friend Mahamadou died yesterday. We first became acquainted with her a few weeks ago, shortly after we arrived here. Her problem was growing weakness, lack of appetite, weight loss, some fever and diarrhea from time to time and recently a persistent dry cough. One of us saw her in the clinic. She was thin, weak and had very abnormal breathing sounds. A screening test for the presence of HIV (the Human Immuno-deficiency Virus) was positive.

To its credit, Niger has a national program for the treatment of AIDS (Acquired Immuno-Deficiency Syndrome) which is caused by HIV. The program is vertically integrated which means it includes periodic clinic visits, appropriate lab tests and also free medication not only to treat the virus itself but also to treat some of the common infectious complications of AIDS such as tuberculosis, chronic pneumonias, and fungal and yeast infections. To enter the program a patient must travel to one of four centers in the country. The closest to us is in Zinder – about a six hour drive to the west.

As soon as the screening test results were available, Aissa was seen by the social worker here and referred to Zinder to enter the program. She and Mahamadou traveled there about three weeks ago. A more accurate test for HIV was performed and confirmed the results of the screening test. She then had some other blood tests and a chest x-ray. One of the most important blood tests, the CD4 count was not performed because the laboratory had insufficient money to purchase the reagents needed for the test. The CD4 test is basically a blood count which gives the number of a certain type of white blood cell. These cells are critical to the function of the immune system and are attacked by the HIV. As the infection worsens, the number of CD4 cells drops. When the count reaches a certain level, the immune system stops working well and all the chronic infections associated with AIDS begin. When the CD4 count reaches this threshold level, antiviral drugs are started in hopes of reducing the amount of HIV in the blood and improving the function of the immune system.

It’s at this point that Aissa’s problems worsen. AIDS treatment and many other health programs in countries such as Niger depend on foreign aid for funding. Assistance may be in the form of government grants or a myriad of other programs operated by non-governmental organizations (NGO’s). These programs usually operate under rather stringent protocols and protocol violations can result in the withdrawal of funds. For example, antiviral drugs for HIV cannot be given unless the CD4 count is at such and such level. Giving antiviral drugs to everyone who just has a positive HIV test is very expensive, and for people who still have a good CD4 count, it really doesn’t help. It may even help resistant forms of the virus emerge, so there’s a good reason for the rule. As a result, since no CD4 count could be done, no antiviral drugs were given to Aissa. Instead, she was instructed to return at a later date for the test and possibly medications. She never made the return trip to Zinder. Her condition worsened abruptly and she died suddenly, probably of an overwhelming pneumonia. In retrospect of course her CD4 count must have been very low. Would the antiviral drugs have made a difference? No one can say.

Her death points out many of the difficulties in administering health care in developing countries. Physicians and administrators have to juggle many different protocols and programs and even though a program is in place on paper, patients may still not benefit.

Many ironies exist in these schizophrenic systems. For example, last year a US based NGO came to this area with a very successful program aimed at eradicating trachoma, an infectious conjunctivitis which is highly contagious but which is also very readily treated by a single dose of an antibiotic called azithromycin. Over a period of thirty days, this well organized program gave the entire population of the region a dose of azithromycin and has essentially eradicated trachoma from the area. Azithromycin is also very effective for the treatment of a number of other infectious diseases including ear infections, venereal diseases, pneumonias and so on. There have been numerous occasions in which the antibiotic could have been used here; however, neither the hospital pharmacy nor any of the private pharmacies here have any. Here’s the irony. The warehouse of our hospital pharmacy contains several thousand doses of azithromycin, due to expire at the end of this calendar year; however it cannot be used because it belongs to the NGO. No one here knows if the NGO is planning to return or to use the medication for further trachoma eradication. The hospital administrator however is very clear that the medication cannot be used by the hospital. For physicians taking care of patients this is very frustrating. NGO’s take a macro view and physicians a micro or individual view. Of course the large programs do much good for many people. It’s just that I’d like a few doses of azithromycin.

Today I went to see Mahamadou. It was the day for visitation. In keeping with Muslim tradition Aissa was buried yesterday – before sunset on the day of her death. Outside the mud-brick wall of his house cloth awnings had been erected and rugs and mats placed on the sand. All the men sat together under the awnings. Inside the wall of the compound the women sat together in the same fashion. Small charcoal fires heated tea. Little was said. It was very peaceful and comforting just to sit together, quietly. Open displays of emotion are not the custom here. If there were recriminations, or anger, or frustration with “a system” I could not detect them. The air was one of acceptance.

Two houses away a wedding was underway with laughter and the sound of the griot’s horn. I made some mention of it.

“We are happy that life continues,” was Mahamadou's reply.

Steve Humphrey
Maine-Soroa, Niger
8 July 2007