Settling and Unsettling--to Africa after all

It's been a while since I last posted, so you'll all be treated to two postings today! Since we left the hotel things have been a little bit of a roller coaster. We moved into our apartment, which we've generally been happy with, a few minor maintenance issues aside. Perhaps the most exciting homefront event was crushing my toe with a headboard while rearranging Ella's room. Nothing broken, but it looked pretty gross (the picture doesn't do it justice, fortunately)... We've also purchased bikes (well, Megan and I did--Hyunjoo is appropriately scared of the traffic here). We've got cell phones, made a few friends, figured out where to buy things. We've eaten tons of excellent food, and begun to use public transportation. All in all, we've started to settle. Having gotten basic needs taken care of, the next task was to get to work. To that end, we've had a few meetings with our local contacts at the clinic where most of the HIV patients in Kunmming are treated. There are estimates of well over 1000 HIV-infected children in the province--most far from the capital. But there are very few that have been identified, even fewer receiving life-sustaining treatment, and just a handful seen at the clinic in Kunming. Given the lack of current patients, our contacts had hoped we could see some adult patients, do some translating, and help with some training, with seeing children being a rather small component of what we do. Well... Our primary purpose in coming here was to treat and care for children with HIV. We're pediatricians, and would like to spend most of our time in the clinic. So, it's been a bit sticky trying to figure out how we're going to proceed. We've suggested some patient identification strategies, but the response has been lukewarm, and it's not clear why. So, we're taking a few weeks to get used to how the clinic operates, see children when they're available, and adults when they aren't, and are reading through a bunch of Chinese documents on HIV/AIDS policies and programs. It's been slow, and not exactly what I'd imagined, but I've learned a lot. I have learned how to say things like, "the appropriate government agencies at the county level and above should implement the AIDS control and prevention policies as dictated by the national council". This week, in clinic we actually saw a new pediatric patient whose mother had been avoiding starting her on therapy for fear that it wouldn't help. When she heard that there were some American pediatricians here, she decided to give us a shot, and we convinced her to start the child on antiviral medications. The mother's primary concern wasn't actually that the girl had HIV, but that she "acted more like a boy than a girl--anything you can do about that?" Ummm, yeah. You can love her... a lot. From a clinical perspective she was doing quite well--nice and chubby, with a boderline profound level of immune suppression based on her CD4 T-cell counts. Fortunately, the only real evidence of her infection was a lot of enlarged lymph nodes, and repeated itchy eruptions on her skin. The kids we've seen so far have all been pretty healthy. I get the sense that the sicker ones that had been identified have all died for lack of therapy. In her case, it was pretty rewarding to have started at least one child on therapy in the first week that we've been seeing patients. That said, for us to be effective, we'll need to find a lot more patients, and those discussions will need to involve our higher-ups from Baylor and our local collaborators. There's a group coming in 2 weeks. Hopefully we'll clarify a number of the patient identification issues, and establish what our role will be and how we can reach the patients in the countryside. In the meantime, we're taking a trip to Ruili this weekend, a town that sits along the Burmese border. It was the first place in China where domestically-transmitted HIV was identified, and is the hardest hit part of the country. We'll meet a few doctors and their pediatric patients to get a sense of the situation there. Then, in about 3 weeks, Megan and I are off to Africa for a month to get some more clinical experience--Megan in Botswana and me in Lesotho. The Baylor-operated Centers of Excellence in those countries see more kids with HIV each day than the total number of kids receiving treatment in all of Yunnan province. So, we're hoping to learn a lot in a short time to bring back with us to China. While we're in Africa, Hyunjoo and Ella are going to spend the month with her family in Korea. It will be hard to be apart (again), but I think given the amount of change Ella's already been through, it will be much easier for her to be in Korea with family than relocate to Africa for a month where everything will be foreign again. Finally, we'll come back to Kunmking in the beginning of November to help with a three week training session about pediatric HIV treatment. Hopefully by that time, the kinks will have been ironed out and we'll be able to get to work in earnest seeing patients here. Although it's frustrating to not be able to do what we'd come here to do, I'm confident that it's possible to get around whatever the obstacles are and do what's needed in terms of providing therapy here. It just takes a while to navigate the bureacracy. I'm sure there's an ancient Chinese proverb that would apply, but I just can't think of it right now.