A Personal Mission: Support for Seropositive Youth in Gabon

     The positive result brought his life to a complete stop: a red light. He didn’t work for months and struggled to make sense of his diagnosis. He had not had many partners and had not used intravenous drugs. Being HIV positive was not what he had planned for his life, a life he had envisioned spending working as an elementary school teacher.

    Slowly he began to accept the diagnosis and integrated antiretrovirals into his daily routine. Eventually HIV became a part of every aspect of his life, including his work.

    Now, after 12 years of antiretroviral treatment, Jules DeL’an is helping other young people with HIV understand their diagnosis. As founder of  “Association Jeune Sida or The Youth Aids Association” he runs an art program for young people, seropositive and seronegative, giving them a safe place to express their feelings. He also serves as a hospital’s HIV counselor, meeting with patients before their test and aiding the newly diagnosed.

The Atelier d'expression has been in operation for more than five years, giving youth and patients a creative outlet. The atelier (french for workshop) is full of paintings and sculptures collected over several years.

    As a part of his work, he conducts artistic activities and one-on-one counseling in an office located near the entrance of Hopital Albert Schweitzer. The room is bright and open, and sunlight comes through the windows to illuminate a collection of artwork. The paintings, tapestries and sculptures that fill the office are at times bright, optimistic and hopeful. Some are more somber and serious.

   On the day that I came to see him, Jules spent the most time explaining one painting. He stood next to it, animated and forceful:

“Aids has no face, but it has feet. It goes from village to village, from person to person. This painting shows the disease walking, walking out of fire and up off the page.”

   The only time I had seen him more animated was when he delivered his daily educational presentations. I first heard of his talks from my roommate, who is another medical student working in pediatrics. She had seen him in the lobby talking to a group of mothers.

    It was a almost a week before I saw one myself. As usual, I was rushing to the laboratory to retrieve results for a patient and, in my haste, almost collided with a gentleman talking to the patients in the waiting room. I mumbled my “sorry” and as I started to walk away noticed he was holding a wooden replica of a phallus. Taken aback, I paused to listen.

        He spoke in a loud, clear voice.

     “HIV is transmitted mostly through having unprotected sex. If you have any questions about how to use condoms or where to get them, please stop by my office and I can help.”

     I didn’t stay to hear the rest of his presentation, but when I met with him another day, I learned that he reveals his seropositivity each time he speaks.

     “Its humiliating.” He said. “And difficult every day and every time. People discriminate and don’t want to shake my hand.” He said, holding out his hand to me.

    What preoccupies many patients in Gabon and abroad , is the question of  “How did I get this virus?” For most that answer is a sexual encounter with someone they did not know was infected. For Jules, the question was a preoccupation as well. He wonders if his ceremony of initiation, a rite of passage for young Fang men, was the source of his infection. During the initiation, he and the other boys in his town were marked with the same razor and given two thin lines, barely visible in his hairline.

     Despite his occasional thoughts of how he contracted the virus, today he is more occupied with educating other young Gabonese people. Here, he says, people are extremely suspicious and, filled with misconceptions of how transmission occurs. In their ignorance, they often condemn those who are seropositive.

      
“ In Gabon we have a name for that judgment, kongossa.” He wrote it on the board to show me, adding adjectives I could understand. 

     I had already seen this kongassa at work throughout the hospital. I sit beside Dr. Fany and Dr.  Justin as they try to educate their patients about HIV and about their sexual health. I have seen many seropositive patients who refused to accept their diagnosis and as a result had not adhered to their (free) treatment.

     The battle in Gabon against HIV is won one person at a time, through the dedication of health professionals and lay persons like Jules. They work to spread the message: For those who seek treatment and adhere to it, life with HIV in Central Africa is not a death sentence.

     As I watched Jules write words of ignorance and misunderstanding on the chalkboard, I saw the teacher he had planned to become. I left  his office with a feeling a deep respect and appreciation; I hope that he continues to find the strength to continue his work.

A Unique Approach: Addressing Sexually Transmitted Disease at HAS

 

One of many STD awareness posters around HAS. These campaign posters are otten entertaining but have a serious message for patients visiting the hospital.

  

      “You need to have a frank conversation with your boyfriend.  He and his other girlfriend need to take the medication too, otherwise the cycle never ends.”

    The young girl hung her head, with a look of such despair and shame, I felt for her. She was only 21, a few years younger than me.

Dr. Carmen spoke again.

   “There is no need to be ashamed. It hurts the heart but look at the white hairs on my head,” She said. “I know about men and their dalliances, as does your mother.”

   The young girl looked up, quietly reappraising the frank speaking doctor. Her mother regarded the foreign doctor with newfound respect.

    She continued, “You have to protect yourself and speak frankly with him.”

   Several moments later, mother and daughter were headed out of the examining room, prescriptions in hand, with undoubtedly much to discuss.

   Dr. Carmen absently dismissed them with her customary goodbye.

“Que Dieu vou benisse and Bonne Guerrisson! May God Bless You and Good Healing! ”

          I was assigned to work with Dr. Carmen in the afternoons on my two very first days in the hospital. She sees patients in the outpatient Polyclinic in each afternoon, addressing everything from tuberculosis to managing hypertension.

      Dr. Carmen is a Colombian born-doctor who came to Gabon over seven years ago. She received her medical training in Colombia and Spain.  Dr. Carmen lost her mother soon after completing her studies and overcome with grief, decided she needed a change of pace. She had always dreamed of visiting Africa,and after contacting several organizations she came across another doctor who was coming to Gabon. She leapt at the opportunity and, in less than one month, she was working in the Hospital Albert Schweitzer. Like so many foreigners who work here, she fell in love with the hospital and its patients. The patients fell in love with her as well and she was asked to stay.

     It is easy to see why she is beloved by her patients. HAS patients are accustomed to foreign doctors but there is a special familiarity and intimacy in the way that they interact with Dr. Carmen.

     On our second day in clinic, a young man came with his older sister because he had been coughing for many months. Like any teenager worth his salt, he slouched in his chair, with a sulky look on his face. As his sister painted a picture of a very ill young man, who had lost weight and had coughed for more than six months, he downplayed his symptoms: He insisted that he hadn’t been coughing for that long.  Then came the inevitable questions about sexual history:

     “ Vous avez une petit amis? Est-ce que vous vous protégé? Do you have a girlfriend? Do you   

       protect  yourself?”

     The young man squirmed, his “too cool for school” demeanor forgotten.“Oui,Yes.” He mumbled, casting a quick eye in his older sister’s direction.

      

When his sister made a face and looked surprised, Dr Carmen chimed in.

“Men, on est sur la planet terre! Ca arrive comme ca avec les filles et garcons. On se voit et le coeur se mettre a battre,” But, we are on planet Earth! It happens that way with girls and guys. We see each other and the heart begins to pound” she said vigorously tapping her chest to demonstrate.

The young man’s older sister laughed at this unexpected dramatization by the doctor and all of the awkwardness was forgotten.

     Perhaps it is because of her accent, with its endearing latin undertones, or her very easy smile, but Dr. Carmen is able to put her patients at ease and discuss the most delicate topics as if she were discussing the weather.

     I came here to learn how to be good doctor outside of the United States. There is a unique skill set for each setting and the setting of a rural hospital in a developing nation requires a unique set of skills, both clinical and personal.

     The most important thing I have learned from Dr. Carmen is to be frank and open with my patients. I’ve learned that to be so blunt, you need a sense of humor and, at times, a few personal anecdotes. It is an art. In the US, it is usually possible to develop a relationship over several visits and address delicate topics once you have established a rapport. But here, where patients come from many kilometers away and may only come once, you have to address the delicate things immediately.

    Approximately 6-8% of the population in Gabon is HIV seropositive, giving the country the highest prevalence in Central Africa and the 13 highest in the world.

      In Gabon, the forms for HIV explicitly classify interpersonal relationships: There is box for married, celibate, widowed and divorced. And also a box for “Concubin” referring to a couple who lives together but is not married. In contrast, positive HIV results are never listed as positive, only subtle markings (such as line under the title of laboratory)or a tiny scribbled CD4 count let you know that your patient is HIV positive. And there are many charts with such notations. 

 One seropositive patient's chart. The circle around the word "Labo" signifies their positivity. It is rare to see "HIV positive" written anywhere on a chart.

     While medical records might be discreet, a doctor in this setting cannot be shy. Rather, they must address the issues surrounding sexual health head on and unblinkingly, because it is a major determinant of health in this population.

On Friday, we returned to the clinic in the afternoon to see our last patient of the day. In fact he was Dr. Carmen’s very last patient in Gabon before she leaves for Germany. 

     The patient was a very nervous gentleman who needed to get the results of his STD panel. We had seen him earlier in the week and finally his lab results had arrived. He sat in the chair with his hands clasped tightly together, almost afraid to move as we opened the envelopes. When we gave him his results: all negative; he jumped up from his chair, both hands in the air.

     “Oh, Merci Dieu!”  he exclaimed and hugged Dr  Carmen and then me.

     Almost as soon as he finished with his hugging and celebration,  she leaned across the table and fixed him with her intense gaze:

 “Men la prochaine fois, mettez vos capotte! But the next time, wear your condom!”

Our First Outing: A Boat Ride down the Ogooue River

 

Papyrus plants line some parts of the riverbank.

    If you google “Gabon”, you might find pictures of forest elephants, humpback whales, “surfing” hippos and the colorful primate, the mandrill.  The nation of Gabon is a unique collection habitats: dense forests, white sandy beaches, marshes filled with tropical birds and an extensive collection of wide rivers. For a much more eloquent (and complete) documentation of what Gabon has to offer, I suggest the National Geographic articles and videos as well as the documentary Gabon: The Last Eden (on netflix).

http://ngm.nationalgeographic.com/ngm/0408/feature6/

     Suffice it to say, Gabon is beautiful with tons to see. However, I work in the hospital from Monday through Friday as well as attending rounds on the weekends; so a four-to-five day trek to one of the national parks is something I haven’t had a chance to do. My roommates and I are planning a few trips, but, for now, we explore the areas surrounding the hospital.

     The hospital is located on the banks of the Ogooue River. In the time of Dr. Schweitzer patients arrived by piroque (Gabonese wooden canoes) and all supplies came from surrounding towns via the river. When I look out of my bedroom window, I can see the river and the dense forest behind it. Most of the time, I struggle to focus on my work and have to close the curtain to get anything done.  

 

The view of the Ogooue from our house.

 

     The river is deceptively calm (there are undercurrents that are quite dangerous) and it looks like a wide, mirrored surface. Every so often the calm of the water is disturbed by a passing motorized piroque. The river extends from the very heart of Gabon, part of the water system that feeds the breathtaking Koungou Falls in Ivindo National Park, and flowing all the way out to the ocean. The province I live in is called Moyen-Ogooue and by the time the Ogooue reaches this area, it begins to divide into a vast delta system. The river creates small lakes or zile where fishing villages have thrived for hundreds of years. One visitor described the zile as “stepping back into time”.

 

The fishermen spend their lives on their piroques, venturing into town only to sell their catch. Their children attend various public schools along the river and commute to school by piroque.

  The tourist centered part of the hospital (what remains of Dr Schweitzer’s original hospital and a small museum) offers day trips on the piroques. There are several destinations, but all trips begin on the banks of the Ogooue. All of the day trips are managed by the ever-friendly and jovial Yaya, whose wife also makes some of the arts and crafts sold at the bookstore. On the trips it is possible to see small groups of apes, a brightly colored reptile called a Varon, many birds and, in the dry season, you might even spot a hippopotamus. 

     Visiting students working at the hospital often join these trips, waiting for big groups so we can split the cost. (Each day trip costs about 90,000 cfa which is roughly $180. Split 6 ways, it is $30 per person.)

The second weekend I was here, I got a chance to take a day trip on the piroque. 

 My roommate and the other tourists getting into the piroque.

It is the rainy season so there were no hippos, but it was still an amazing experience. So many times during the trip, I looked out on the water and was overcome with emotion. I feel blessed to be working in such a beautiful country. I tried to take as many pictures as possible and here they are:

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First Days in Lambarene and the HAS complex

My brief moment of “zen” was quickly interrupted when our driver yelled for us to get back in the truck. We started to head out of town taking RN1 (Route National 1). The road for the first hour was badly in need of repair and, although Ayesha and I kept falling asleep, we would systematically wake up whenever there was a particularly huge pothole.

   When I was able to keep my eyes open, I saw many small towns, with well built houses and many people. Almost every signle Gabonese home, no matter how small or humble has neon strip lights out front. I asked the driver if they were for killing mosquitos and he responded that they were more energy efficient and cheaper. It was strange to see because you could see all of these neon lights in the distance seemingly floating in the mountainside.

  Four hours later we arrived in Hopital Albert Schweitzer in Lambarene. I was so drowsy I didn’t even look around. I just blindly grapped for my suitcases, and lugged them behind our driver. He unlocked a door and I saw our house for the first time. Here is some pictures of my  house and some of the views from our windows!:

It was surprisingly cozy and well equipped. The house has been used for students from all over the world, the most recent inhabitants were two Swiss medical students. There are four separate rooms each with its own locked door, a living room and kitchen area (equipped with a gas stove). Some perks of our house are warm water, drinkable water (available throughout the complex), a flushing toilet,  pretty consistent internet and an awesome porch overlooking the Ogooue River. There are some downsides to our house: many many holes in the screens, the most spiders I have ever seen and gigantic roaches. 

      We immediately started cleaning, removing cobwebs, dodging spiders, using clorox to clean everything in sight. The first night, we finished cleaning and, because it was late, fell asleep under our mosquito nets. After three days of travel we were exhausted.

      I woke up to the sounds of our new home. There is a chicken, (nickname: alarm clock), who is convinced that dawn is at 3:30 am. He is adamant that while the rest of the world sleeps, the inhabitants of the student house MUST be awake at 3:30am.  In fact there are chickens everywhere, beautiful variegated chickens that rest on every perch available. Here is a shot of our chickens that I took early one morning.

   I was in for a surprise. When I looked out of my window, I was in complete shock. I have concluded that Ayesha and I work in paradise. The river is immense and beautiful. The mountains in the distance are covered in dense forest and everywhere you look is green.

   My favorite thing to do each morning before work is to just stand at the window and look at the trees on the riverbank. They are my constant photo subjects.

   The hospital complex itself is a small village. The hospital was built in 1913 by Dr. Albert Schweitzer, (who I will dedicate an entire post to soon.) The original hospital is now a tourist attraction, with a museum and daily tours of the old hospital. The modern hospital has 152 beds, 6 physicians and 250 total staff, most of whom live on the complex. There are five main services: pediatrics, adult medicine, surgery, maternity and dentistry. The hospital sees approximately 30,000 outpatient visits/year (>60% of all patients seen in the Moyen Ogooue region), 6,200 inpatients/year and 1,500 births/year. The complex is also home to a world-renowned Medical Research Unite (with a focus on malaria) and a thriving public health program for mothers (Protection Maternelle et Infantile). 

 Aerial Photos Courtesy of Albert Schweitzer Foundation

    There are two restaurants, a seamstress, a laundry, a small food store and even a small outdoor market during the week under a large tree. Most of the people who work in the hospital also live on the hospital grounds. It is not unusual to see the same nurse who helped me move a patient in the morning, at her house in the afternoon cleaning fish for dinner. There are schools for the elementary and middle school students and in the afternoons, their excited post-school chatter drifts through my window. The older kids host heated soccer games on the soccer field in the middle of the complex .

    The physicians all live in the complex, including the surgeons, pediatrician, internists and dentist. In fact, the dentist’s clinic is across from our house and he, his wife (a nurse in pediatrics) and their two small children live in an apartment directly below the clinic.

     In my next posts, I hope to focus on my life as a stagiare in the hospital’s adult medicine service (Ayesha works in pediatrics). The cases are fascinating, and I have tried to capture the pertinent information about what I have seen so far. For clarity, I have decided to focus on a different aspect of the medicine service for each group of posts, rather than trying to relay everything chronologically. First up is sexually transmitted diseases and the HIV epidemic here.  

      

Safe Arrival in Libreville

I blinked my eyes and woke up in another continent. It seems that everything, from receiving my acceptance email to landing in Libreville, all happened in the span of that blink. There was so much to prepare and arrange that I didn't have time to absorb it all.

    Holiday Break: I received 6 vaccinations. Two one day (yellow fever and Hep A) and four the second (typhoid, tetanus booster, and two other I can't remember). I spent two days aching, convinced I had overdone it. Then I called the travel agency and booked my tickets. My next big task was to secure a visa from the Gabonese Embassy in Washington. It took some fancy footwork, two passport photos, a hundred dollars and clever mailing, but I received it three weeks later. Then my mother insisted I arrange some checkups  and a quick visit to the dentist. I didn't get around to visiting the dentist until I made it back to Winston Salem. (Note to self: going to the dentist during your week on inpatient nights = very long  and painful night). Lastly I bought my malaria prophylaxis: 135 giant blue doxycycline pills: one for a few days before, after and everyday of my trip.

    Friday Jan 27th: Internal Medicine Shelf! I stopped all planning for the entire month and just focused on my test. No passing medicine grade = no Africa. Or at least that is how I saw it. My parents came via train (dad) and plane (mom) to help me pack.

    Saturday Jan 28th and Sunday Jan 29th: Whirlwind shopping frenzy. Thank goodness for thoughtful, kind and patient parents. We went to Walmart (three times), Lowes, Target, Dick's, the mall, the post office, two banks (for traveler's checks), my landlord's home, and the supermarket. Some of the highlights of our shopping: 120 granola bars (one for every day), rain boots (Feb1-May1 in Gabon is rainy season), mosquito netting, bug repellent, flashlights, batteries, mac and cheese (essential) and extra scrubs. On Sunday, I made my fourth year schedule and had a few friends over. I ate dinner with my parents and enjoyed a few last moments with them.

    Monday Jan 30th: Departure day! My parents and I spent a hectic morning attempting to track down euros at a good exchange rate. Then we drove to Charlotte so I could catch the first of many flights. On the way to Charlotte, we called everyone in my family. I said bye to my grandmother who reminded me to be careful, said bye to my uncles and aunts, brothers and sister, cousins, niece and nephew. My journey to Lambarene looked like this:

    Flight 1: Charlotte to Boston ( to meet up with Ayesha Rabbani, the other fellow)

    Flight 2: Boston to Paris (overnight flight)

    Flight 3: Paris to Libreville, Gabon (afternoon flight on the 31st)

    Three hour car ride from Libreville to Lambarene

     Monday Jan 31st: It didn't hit me until this exact moment, when I looked out of my airplane window and saw mountains. I checked the plane GPS map and saw we were over North Africa. The next time I looked out of the window we were over the Sahara. For the first time since I started this journey, almost three months ago when I completed my application, I was terrified.

    As we prepared to land, fear filled me. What was I doing? I had never been this far from home.  When we landed and the doors opened, I braced myself and entered the airport. I found Ayesha and we filed into the security line. Of all things that could go wrong, what worried me the most was something being wrong with our visa. I already knew that someone from the hospital was here to pick us up (my second most pressing concern). A kind Gabonese woman had lent me her phone to call the hospital, and they notified us that a driver was already waiting for us.  Thankfully we had no problems with our visas and found our bags and a woman from the hospital quickly. It was fun to see our names written on a piece of cardboard.

    Our driver tossed our bags in the bed of the truck, and we zipped around to do a few hospital errands before leaving town. All around me I saw activity, people driving, walking, colorful materials everywhere. We arrived on a very busy day in Libreville, one of the semifinals of the African World Cup. Gabon was playing when we arrived and everywhere we looked we saw groups of people huddled around televisions, following the game.
     We stopped at a gas station to fill up and to throw a tarp over our suitcases (to protect them from the certain downpour). As soon as the driver stopped and jumped out, I hopped out of the back seat. I leaned against the door and took a deep breath. I told my father before I left that as long as Gabon smelled like Haiti I would be ok.  For anyone who has ever traveled to the Caribbean or to a developing nation with a warm climate, you know there is a smell, a unique group of smells actually, that these places have. For me those smells are tied to so many wonderful memories I had as a child in Haiti, memories full of excitement, happiness and discovery.
    I took in a deep breath and crossed my fingers: Gabon smelled like Haiti.  I started to smile because all around me people were talking in super fast french, carrying baskets, children hanging from the backs of their mothers and cars horns honking frantically: Yes, everything was going to be ok.