The doctor kneels on the concrete floor and prods at the young woman’s spine with a gloved finger. ”It’s going to be difficult,” he mutters, then pushes the needle into her skin. She gives a low moan as the needle slides in and out.
The young woman has meningitis. Draining some of her cerebrospinal fluid, the clear liquid which flows through the backbone and around her brain, will relieve her pain. But she is overweight, and that makes it difficult for the doctor to find the right spot. It takes several tries.
In a western hospital, the treatment would have been done by the insertion of a valve to drain off the excess fluid. But this is Arua regional hospital in Uganda and the patients are accustomed to pain and grateful for the limited treatment that is available.
In the grounds of the hospital, run by the Ugandan ministry of health, the medical charity Médecins sans Frontières runs an HIV/Aids clinic where new patients arrive after testing positive. One of the MSF staff, a nurse, also works full-time in the hospital’s isolation ward, treating patients with infectious diseases such as TB.
MSF is a victim of its own success, running an HIV programme that after three years has 6 000 registered patients, more than 2 000 of them on anti-retroviral drugs. Every month there are between 100 and 150 new admissions. Some come from neighbouring Sudan and the Democratic Republic of Congo.
They travel to MSF’s clinic in Arua because there is little alternative. Government-run health centres in outlying regions do not have the resources to cope. ”Most of the health centres don’t have support from an NGO [non-governmental organisation],” says William Henniquin, MSF’s field coordinator in Arua. ”They don’t have enough staff, or they have the staff but they are not trained.”
When the programme started, MSF staff had the time to visit patients at home. Now there are too many to check up on at home. The result is that more patients drop out of ARV treatment. In October 2004, 65 people had dropped out from about 1 350 patients on ARVs — less than 5%. A year later, 340 of the 2 650 patients — 13% — dropped out. Patients who fail to keep up with treatment do not just put their own lives at risk, but increase the chances of producing new strains of the virus that are resistant to standard treatments.
In the longer term, the answer is a better funded and more efficient health service in Uganda, but that is a long way off. The Arua hospital management says its grant from the ministry of health has remained unchanged for three years.
Out of 16 specialist posts in the hospital, six are vacant. The hospital should have 10 medical officers but only three posts are filled. With greater numbers of patients, the counsellors and medical staff in the HIV/Aids clinic get to spend less time with each one.
In the clinic, the doctors and clinical officers ask patients a brisk round of questions aimed at pinpointing how much of their immune system remains.
Alidra Yekonia, a tailor, has lost 17kg in two years and has had a fever for more than a month. Dr Ahmed Saadani, a Moroccan MSF doctor, refers him for further tests which indicate that he has extra-pulmonary TB — the disease has spread outside his lungs into the rest of his body — and he is admitted to the isolation ward.
The isolation ward is a row of dark rooms with grimy walls and cracked window panes. Lauren Cohen, an American nurse, is here on her first MSF posting. In one of the beds, Charles Okwir (38) lies dying. An obstruction in his bowels means he cannot digest food properly but the cause is a mystery because there are no x-ray or scan facilities.
”He’s right now taking his train to the active stage of dying,” Cohen says. ”He’s the biggest mystery. He’s received every single antibiotic. He’s clearly suffering. He’s anxious and all he talks about is that he wants to die so he can have some rest.”
There is little the nurse can do. ”We don’t have a lot of pain medication. He’s on liquid morphine, and I’ve just given him Valium.” – Guardian Unlimited Â