crimes against humanity?

recently i read a post that really touched me. it got me thinking a bit about the recent suggestion to charge mbeki with genocide because of the fact that his denialist policy has resulted in so many hiv related deaths. politicians always amaze me.

the story in the post is not unique in south africa. truth be told, those children actually have it quite good. they have someone who loves them looking after them and that someone is on antiretrovirals, so she should be around to bring them up. there are many more aids orfans in a much worse situation. there are also thousands of children infected with the virus today as a direct result of the mbeki regime.

now i'm but a lowly surgeon. i can't see the big picture. my mind gets stuck with the individuals. i'm touched by the plight of these children and i'm shocked that mbeki washes his hands of them. when blinded as i am by the suffering of these little ones, i just can't seem to appreciate the important effects of mbeki's decisions, like his career and the anc maintaining a façade of having things under control. somehow the little people are more important to me than all those anc fat cats.

interesting to note julius malema's reasons for not pursuing the charge of genocide against mbeki. he says they should not charge one of their own. i just wonder, why are those innocent children not one of their own too? is one man, mbeki, more important than thousands of lives and the devastated lives of all these children? a good anc answer would no doubt be most definitely! but somehow i have my lingering doubts.

as usual the anc takes no responsibility and the people that suffer are the innocent.

maybe not genocide, but what about charging mbeki with crimes against humanity?

injuries

every sport has its injuries. so the saying goes. and surgery is no exception.

it was a thyroidectomy for multinodular goiter. not like the monsters that the state was inclined to deliver, but a routine straightforward private thyroid. the only catch was that she was hiv positive and not on antiretrovirals. the cd4 count was low but acceptable so i went ahead.

the operation went without any hitches. quite soon i found myself placing the last skin sutures. and then... i stuck the needle into my finger. let me assure you, that is not the greatest feeling.

anyway, before the next case the first dose of antiretrovirals had passed my lips and i felt slightly consoled. only slightly.

the month flew by quite quickly actually. the only side effect i experienced was diarrhea but, truth be told, that was bad enough. i actually considered suggesting antiretrovirals as suitable bowel preparation for colonoscopies. no one took me seriously.

thereafter i needed to have the obligatory test. the only problem is in such a small place as the town where i live, if i tested positive, within a week everyone would know my status. if it were to turn out positive, i would basically have to shut down shop and find another town to ply my trade. who would go to a surgeon with hiv? i had to have the test done anonymously.

i approached my good friend, the pathologist at the lab. he understood my situation and agreed to do the test for me under an assumed name (i think it was something like 4739). that friday he drew my blood. i was on call so i immediately disappeared to theater. he assured me he would call me in an hour.

an hour passed. another hour passed. i tried not to panic as a third hour passed. to phone him would show a serious loss of cool but after another hour i didn't care about that anymore. i got his voice mail. at that stage i started making plans in my mind for my new practice in a small town in another province. a friend of mine there was looking for another surgeon to join their partnership. like most places in the country they were overworked due to the country wide shortage of general surgeons. it would be a pity to have to start from scratch but the fact that i had heard nothing from the lab implied i must be positive, or so i reasoned.

the fear of hiv is a part of the job. occasionally taking antiretrovirals is also part of the job. in a setting where probably 30 to 40% of the population has the virus it is inevitable to have contact occasionally. it is just one of the things we must face day to day.

then he finally phoned. they had done all the tests imaginable and i was negative. the relief was difficult to describe. when you've seen the effects of the virus so many times, especially the dementia syndrome it causes, the fear of it is a constant cloud over your head. the moment of sunshine then was beautiful.

too good to be true

just a quick update.

if something sounds too good to be true, it probably is. the possibility of the downfall of manto therefore won't happen. interestingly the anc has now claimed they were always aware of her conviction of theft. maybe they viewed that as an attribute that perfectly qualifies her for a top position.

seems she got her liver transplant legitimately (hmmm?). she has at no stage questioned allegations of alcoholism, so i think we can assume that the reason for the liver failure is self evident.

thabo mbeki, the president has publically praised the minister as a hero of the people (the hiv negative ones maybe) and stated that she is doing a great job.

meanwhile some guy writes a book about what a great leader thabo mbeki is. he then goes on to say that all people who have been advocating antiretroviral drugs as treatment for hiv owe the afforementioned 'great leader' an apology. this has to do with the fact that antiretrovirals have more side effects than garlic and beetroot (which is what thabo and manto propose as first line treatment of hiv)

so, in summary, our convicted thief health minister who denies the use of antiretrovirals as important in the fight against aids is not only still in control but fully backed by the government of the day, the anc.

paradox

recently i heard a story that really made me laugh. about 45 minutes from nelspruit is a sponsored aids clinic. it is financed by some international group. it is manned by doctors and nurses. it also employs 'aids' (no pun intended. that's actually what they are called). the aids were all patients at one time or another. they mainly act as interpreters, but fulfill many menial tasks

anyway what happened is that a vicious rumour started up that one specific aid was not actually hiv positive. the other aids started complaining and actually wanted her fired. it caused such a rucus that the doctor working with this aid was asked to surrupticiously "please just confirm that she does have hiv".

so people discriminate. hiv positive people will even discriminate against those that don't have it. this is truly the first incident of someone almost losing their job because of not having aids.

the powerful horn

the basic topic behind this post it seems to me will tend to reccur. i therefore must accept it and get on with the post.

i presently have a patient in my care who has a very tragic story. he is hiv positive with a cd4 count of 25. (not good). he works in umtata in the eastern cape. there he went to a sangoma, apparently complaining of chronic diaree and generally not feeling too well. the sangoma decided the needed treatment was an enema administered through a strong bull's horn. the horn was duly inserted into the anus, through the anteriour rectum wall and the enema was pumped freely into the peritoneal cavity. (although a strong bull's horn might be the desired mode of administration, possibly because a weak bull's horn would have lesser curing potential, i personally think that something slightly less traumatic may just suffice). as you can imagine, the patient didn't improve. in fact he got worse. he then presented to a surgeon (a few days later) who operated. the rectum was repaired, the abdomen was rinsed and that was that. or was it??

a few days later, the patient developed acute abdomen again. the surgeon took him back to theater. the notes report he found multiple spontaneous perforations of the cecum (completely the other end of the colon) as well as breakdown of the rectum repair. these were all repaired, a transverse loop colostomy was brought out and pensil drains were left in the abdomen. the abdomen was only loosely closed.

at about this stage the patient mentioned he came from nelspruit and was duly posted off to me. when he arrived here, he was in prerenal kidney failure, his liver enzymes were totally deranged (possibly overwhelming sepsis but just as possibly the direct known hepatotoxic effect of many sangoma concoctions) his viral load was as high as his cd4 count was low and his white cell count was a dismal 2,6 as opposed to a crp of over 300. he was leaking feces from everywhere. the entire laparotomy wound was one massive contaminated mess.

what to do?? i decided to operate (after appropriate attention to his fluid state). inside was a sewer. there was no corner of the abdomen spared. my basic plan was to exteriorise everything. inside the cecum was a sieve of multiple holes and necrosis. the rectum had broken down again. there was also a spontaneous hole in the small bowel (middle). i did a right hemicolectomy with an end ileostomy and brought the colon out through it's own site. i debrided and repaired the small bowel hole. i rinsed copiously. i placed drains absolutely everywhere. i placed a post treitz feeding tube. i closed with tension sutures. i bundled him off to icu. i prayed. i might have muddled the order of things, but icu was towards the end. what was interesting to note at operation was the total lack of fibrin or any adhesions in the abdomen. the body wasn't even trying to heal itself.

the patient still developed leaks. i'm now going for controlled fistulas. some things are not so bad. he is no longer intubated. his kidney function recovered. his liver function is on the mend. but quite frankly i wonder what his chances are with zero immune response and zero healing.

i wish i had more time to discuss this case. there are so many interesting points. a starting point may be the fact that my physician friends told me i should have left him to die, arguing that it was not right to dedicate a long term icu bed to someone who would die anyway, thereby depriving the bed from someone else who has a chance. besides the obvious feelings of loss and failure if he dies, i'll be the butt of many of their jokes. the converse is not true. if he lives there will be no acknowledgements or accolades.

the other point is the sangoma and his role in the treatment of hiv. bear in mind our minister of health publicly says their role is crucial. i differ somewhat. (this is not an isolated incident). it is always also fascinationg to me to see how they are totally absolved of responsibility when things go pear shaped. in fact if the patient dies there will be fingers of accusation levelled at the western medical establishment from them. "see even the western doctors couldn't save him" or worse "look how sick their western medicine made him".

but if i could give any advice, when you have hiv and your cd4 count is 25, don't get a rectal perforation. it is not a good idea.