Abdurafi is a small village in Ethiopia close to the border with Sudan that I called home for an unforgettable nine months. The river on whose bank it lies is the lifeline of the region and at the same time a source of great enjoyment for us MSFers who go swimming every weekend.
Every year, an estimated half a million young men from the highlands of Ethiopia descend onto the plains around Abdurafi with the onset of the rainy season; they work as migrant seasonal workers on vast farm lands owned by rich Ethiopian and foreign investors. Along with money earned for their hard work toiling in the sorghum, millet and cotton fields, some of them also contract kala azar, also known as visceral leishmaniasis.
Kala azar is a neglected tropical disease spread by the bite of the tiny sandfly and is fatal in most cases unless timely treatment is initiated. Since it has a relatively slow progression, with initial symptoms appearing over two to six months, many of these non-immune young men only develop the disease after going back to their homes in the highlands, where healthcare workers are not trained to diagnose this disease.
MSF thus plays two very important roles: health education for these migrant workers; and treatment of kala azar in the 126-bed hospital that we run in Abdurafi. While treatment of kala azar is difficult due to lengthy regimens and limited drugs, the presence of HIV complicates matters even further.
HIV-kala azar co-infection is one of the most frustrating and challenging things that I have come across as a medical doctor. This is because of the propensity of HIV patients to relapse with kala azar within a few months of curing the initial episode. With every subsequent relapse, treatment of kala azar becomes even more difficult, due to the development of resistance to the limited number of available drugs, as well as to the deteriorating condition of HIV patients and the development of other opportunistic infections such as tuberculosis.
This part of Ethiopia has the highest proportion of HIV-kala azar patients in the world. Working in this area gives MSF the additional responsibility of conducting research, above and beyond taking care of the healthcare needs of the population. Operational research is an aspect of MSF’s work that does not get highlighted as much as it should, but it will help save the lives of patients such as those with HIV-kala azar co-infection who I encountered and will always remember. During my time in Abdurafi, a prospective cohort study using monthly injections of pentamidine as a prophylactic agent to prevent further relapses of kala azar in HIV-infected individuals took off the ground. I am positive the results of this study in a few years time will help shape clinical guidelines in the care of such patients all over the world.
Through this letter about the field, I have tried to shed light on one aspect of the work that MSF does in furtherance of the care of people with limited access to quality healthcare. I thoroughly enjoyed the medical work, the rich cultural experiences and making lifelong friends, all of which are equally important parts of life in the field.
A veteran MSFer told me to be prepared for chance encounters with old friends on a small part-time airfield in an obscure (yet completely enigmatic and exciting) part of the world. Bring on my next mission, MSF!
-Dr. Alan A De Lima Pereira
