Migori, November 2014
It’s 10 o’clock, which is to say, Teatime, and the necessary accoutrements materialize: a massive plastic flask that advertises it can keep liquid hot for 6 hours, discarded boxes and baggies that have graduated from holding nevirapine and Truvada to cocoa and Tangawizi chai, and insulin syringes, which in a pinch, it turns out, are little different than tea stirrers. Dog-eared manila folders cascade across the desk, an avalanche of the morning’s work. The floors are scuffed, the faucet broken. A sheet with viral load figures bears a stain of samosa grease. But – before you judge – pick up that sheet.
There are five scrawled handwritten columns on the left side of the paper, writing crunched to fit in all the patient ID numbers. There is one column on the right, perhaps 25 entries. The left side is labeled, “Viral Load Undetectable”. The right side is the medical record numbers of patients with detectable viral loads. I imagine a similar exercise in San Francisco, what it’s like surveying the viral loads of those who come into HIV urgent care, and I don’t know for sure, but I think FACES would give us some stiff competition.
“Think how many millions upon millions of copies of HIV virus do not exist in Migori because of you,” I tell Edna, one of the clinical officers who will see forty patients today and forty patients tomorrow and the next day and the next. She stirs more sugar into her tea. She’d never thought of it that way, Edna says; she just comes to clinic and does her job.
What impresses me most about her work, in fact, and those of the others at FACES, is that as an internist, I am not needed, because the patients, except the newly initiated and the minority with adherence problems, are not sick. HIV can be controlled through a public health nursing approach. The skills I could lend in treatment of opportunistic infections are superfluous when one patient after another comes in well and virally suppressed. Edna’s job largely involves eyeballing the patients, querying them about adherence, swiftly ticking a bunch of boxes, handing out refills, and sending yearly viral loads. The fact that it is not thrilling is a testament to the success of FACES.
The mugs are now empty but for a sticky glaze of sugar, and the insulin syringes are headed to the sharps container. Teatime is over. Edna turns to the avalanche on the desk and grabs a file. “Margaret Otieno,” she calls out, and a woman in a purple kanga strides in, ARVs in hand.
One patient at a time.