Pooja Shah, MD
Lesotho: April 2008

I learned that barely a month in the country of Lesotho can envelope a traveler into the arms of the land and people. The Basotho are kind, warm & grateful (and often speak so very loudly!). The evening I arrived in this country, I walked away from the Maluti Adventist Hospital, a patch of buildings in the middle of nowhere, down a cobbled path that turned into uneven red dirt toward my little house. Three black & white cows brayed in the twilight that envelopes this mountainous country when 5:30 PM comes. Kingdom in the Sky is Lesotho's epithet. It is fall, and my arms reminded me of that quickly as goose bumps rose on them while the last bits of sunlight disappeared. My eyes caught several angles of the hued dusky sky beyond the thick trees. I was awed. Mountain vistas of red earth, drying with the onset of autumn, dotted with the greenery that sprouted from the summer-end rains of February & March, overtook me. With each minute past, dots of light began littering this unearthly landscape, people settling into another Lesotho evening. That day, I was overwhelmed, but when you're a doctor, you're not allowed to show it. I was thrust into the Paediatric ward of the hospital that morning as the only doctor left in the hospital that knows anything about kids (I am a Family Medicine resident). The three Pediatric residents from Boston were away, enjoying a much needed 3-day respite of horseback riding 5 hours from Maluti. This place is funny like that. If you're a volunteer doctor here, and you decide to go away, you freely can. The problem is, there simply may not be anyone to take your place. And that is why I suddenly felt the immense weight of responsibility drop onto my shoulders that day. The inpatient children were relying on me, as was each kid that arrived in the outpatient department.

I walked into Lesotho not quite understanding why the legacy of the American doctor is tied up in the attempt to save every life of the truly destitute, the dying. Now I know. HIV or not, once one of these children look into your eyes, time stops & now begins. Some are so sick it's hard to look. One kid, a mere 1 month of age, was covered in huge blisters, skin denuded, mouth covered in sores so serious he can't suck off his mom's breast; his diagnosis: bullous impetigo, and he was getting better with an antibiotic the Western world is too proud to use. Another kid is 3 years old. He had a CD4 count of 24, which translates to end-stage AIDS. He had TB and yeast coated his entire oral canal. He also carried the diagnosis of malnutrition. His spine resembled a step- bridge, his ribs a xylophone. And yet, if he could muster up the energy, he would run down the hallway in his fuzzy train-printed pajamas, just like any American kid. Most of the time, though, he was resting, a bundle snugly pinned under a thick blanket on his mother's back. He's adorable. It's not his fault he's dying of AIDS and tuberculosis.

The disease has become so pervasive that it's understood as the norm, the status quo. In the O.P.D. (Outpatient Department), where we spent at least half of each day, I encountered the statistics daily. Before I arrived, I was told that you will start to recognize the face of AIDS. It's true. And it's heartbreaking. Basotho men and women, generally just after their child-bearing prime (35 - 42), are wasting away like human skeletons, with sores or thrush or eyes that gaze but can't see. To see a doctor (or as it would be, often a fourth year medical student,) people must pay their R15 (Rand), wait in the never-ending O.P.D. first-come-first-serve line, seated on crowded benches of the waiting room shoulder to shoulder. They may wait all day, and when they finally make it to one of us, they realize their laundry list of symptoms might mean HIV. Many are willing to be shuttled off to the "Wellness Centre" (a euphemism for HIV/AIDS clinic) to be rapid-tested for the virus (which, when positive, is recorded in their bukanas as "ICD [Immune-Compromised Disease] significant". But some are too scared of the truth, and so you give them analgesics and symptomatic remedies, and in return they give you their empty promise that they'll come back "next Friday" to be tested. The euphemisms abound and you begin to realize that the reality is still lurking in the dark. No one dies of AIDS here. Not if you ask anyone how their _____ (fill in the blank - mom, father, aunt, brother...) passed away.

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The Benjamin H. Josephson, MD Fund
Overlook Medical Center / Atlantic Health System
Summit, New Jersey
908-522-2853