Paul Farmer reports from Lesotho on the eve of the PIH project's first anniversary

By Paul Farmer

Valiant is the word that comes to mind when I think of Lesotho. I see courage and strength manifest in this small country’s people, some of whom PIH is beginning to serve through clinics and projects. Valiant too are the growing number of people from the Ministry of Health and its NGO partners, who are accomplishing these projects in spite of adverse circumstances. Lesotho has one of the largest burdens of HIV in the world and, consequently, may have the world’s highest incidence of tuberculosis. (TB epidemics almost invariably accompany AIDS.)

	Doctors making a home visit in Lesotho

This beautiful country is called Africa’s “kingdom in the sky” for good reason. Even the lowlands are 3000 feet above sea level, and far more striking are the tall ranges of treeless mountains, which in winter (it is winter now) are covered with snow on their southern faces. The very settlements we seek to serve are spread out across this forbidding terrain, making travel to clinic arduous for the patients; home visits by staff, inexperienced unless they’re mountaineers, are also difficult. These challenges only stiffen the resolve of PIHers and their local partners, continuing a commitment first undertaken while PIH co-founder Jim Kim was working at the World Health Organization.

When in 2005 PIH and the Clinton Foundation, along with local partners, launched a rural AIDS initiative in three African countries, we knew we would have to do three things at once: take care of the sick; face the “human resources” crisis through training and working alongside of African colleagues; and rebuild public infrastructure destroyed (as in the case of Rwanda) or simply not equipped for the advent of a new disease, AIDS, and the resurgence of an old one, tuberculosis. We also knew that we’d have to do all of this while attending to the innumerable other health problems faced by undernourished rural people who had never had much in the way of primary health care, to say nothing of treatment for AIDS or, in the case of Lesotho, drug-resistant tuberculosis.

Lesotho, with its terrain, the dimensions of these twinned epidemics, and the near-total lack of physicians in rural areas (there is not a single medical school in the country) posed the greatest challenges for the Clinton-PIH Rural Health Initiative. Within Lesotho, the nine sites in which we are to work are not contiguous, but rather scattered across the high reaches of the east and south. Many are accessible only by plane or on horseback. Yet after only a year of operations, PIH-Lesotho, led by Dr. Jennifer Furin, has attained and surpassed many of our goals in places where few thought it possible. Spurred by a deadly outbreak of extensively drug-resistant TB (XDR-TB) in the neighboring South African province of Kwazulu-Natal, a second program to treat and prevent drug-resistant TB has also already begun, funded by the Open Society Institute. A brief July visit to the mountains and to the capital city of Maseru affords me the chance to update supporters and friends of PIH-Lesotho.

Baptism by Fire: The New “OR” in Nkau
When Jennifer Furin joined us in Rwanda for a June meeting, she was especially pleased to give us the news: finally, PIH boasted two young Basotho physicians, Dr. Nico Lesia  and Dr. Limpho Ramangoaela. Having finished their training at Bethlehem Hospital in Orange Free State, South Africa, both wanted to return to serve their own people. During a weekend clinicians’ retreat in the town of Nkau, Dr. Limpho told us how they came to PIH. She went to see  Dr. Mphu Ramatlapeng, who headed the Clinton Foundation’s work in Lesotho at the time and has since been named the country’s Minister of Health, and said, “I want to come back home.” With the frankness for which she is famous, Dr. Ramatlapeng replied, “Are you serious? If so, do you know any other recent graduates from Lesotho who wish to return?” Dr. Limpho said she did. Soon both she and Dr. Nico would find themselves high up in the mountains and grateful for their good and broad medical educations.

I saw first-hand how effective their education had been, since the clinicians’ retreat was interrupted by a number of emergencies. During a single afternoon, we saw more than one type of trauma. A young woman with cerebral palsy who had been raped was brought in by her mother because the family feared (correctly as it turned out) that she was pregnant.

	Stitching by candlelight in Nkau

Shortly thereafter, as the sun was setting, a young man named Tseliso managed to stagger through the doors hours after a machete attack. He had serious wounds in his head, back, and wrists; the lacerations went to the bone. He needed medical care desperately and, as chance would have it, there were six doctors that day in a village where normally there are none. A few minutes after their arrival, Tseliso and his brother (also injured in the attack) were being cleaned and stitched up by Drs. Nico and Limpho, and also by PIH’s Dr. Mona Haidar. Because Tseliso’s injuries required careful cleaning and over 200 stitches, the doctors were soon sewing by candlelight. Without narcotics on hand, the patient received only local anesthetic, but he made no complaint except to say, even before the suturing was done, that he was hungry.

Tseliso after 200 sutures and multiple bandages

It took a couple of hours to patch Tseliso up, but his injuries would require further skills, since at least one of his wrists had been broken during the attack. Jen arranged to have him airlifted on Monday to Queen Elizabeth II Hospital in Maseru to see one of the two orthopedists in the country. After the patients were tucked in for the night, Dr. Nico told us what had happened. At 8 o’clock that morning, the two brothers were attacked by men who had been grazing cattle on their land without permission. (This made me think of the nineteenth century Boer incursions into these regions for the same purpose: to take over Basotho grazing lands.) The usual arrangements stipulated that the cattleherders go to the chief’s kraal to pay a grazing fee. Instead,Tseliso and his brother awoke one day to find strangers and cattle on their land, and, following convention and customary law, asked them to leave. The next day, Dr. Nico explained, they were attacked at their home by a group of men with machetes. Left bleeding and in great pain, they had to walk three hours from their home village to the clinic in Nkau.

	The Nkau operating room team celebrates

Dr. Mona has been in Lesotho for six months, and has seen plenty of trauma. This was, she said, a more aggressive assault than any she’d seen, with the exception of a man killed by an axe blow to the head. High unemployment, poverty, labor migration back-and-forth to South Africa, and substance abuse conspire to create an environment in which the PIH doctors expect to see trauma on a regular basis. Tseliso and his brother were lucky, in a sense. Though gravely injured, both can expect to recover completely.

Home visits

	An AIDS patient and her accompagnateur near Nkau

The next day was dedicated to home visits, an activity conducted at all PIH sites. While Jen took off on horseback to see a critically ill patient hours in one direction, I had the privilege of spending the day walking to severely ill AIDS patients in another. I followed Nico and Mona. Although the patients we visited were very ill, all were responding to therapy. It was a long and satisfying hike, despite some haunting scenery of abandoned houses and mission schools. The population in rural areas of Lesotho is shrinking, as people migrate to cities in search of work and HIV has reduced life expectancy from 60 years to less than 40.

Later that day the team celebrated a successful candlelit surgical intervention, rewarding home visits, and a fruitful retreat. Dr. Limpho revealed that she had, in addition to her clinical skills, a good deal of talent as a chef. Jen had bought a sheep for her staff and visitors. As we were enjoying barbecued mutton, one of the village elders, who told us he was 73 years old, praised the doctors and nurses in straightforward terms: “Never before have we had doctors and nurses live among us up in the mountains. You are a gift from God.”

In Maseru
The next morning, with the help of our friends and partners in Mission Aviation Fellowship, we were able to airlift Tseliso to the country’s main hospital (the partnership between PIH and MAF was profiled recently by the Baltimore Sun. The emergency room was crowded with all sorts of patients, some of them seeking, I suspect, primary care; others came with wounds. Without Dr. Nico, it would have been hard to wade through the crowd and find the right place to wait. After we got Tseliso settled on a bench, referral letter in hand, Nico went to find a boy who’d been referred for surgical management of chronic osteomyelitis. This child had been sent to the hospital from the mountains and was happy to see his doctor. Every time I heard Nico and Limpho speak to patients and family without the help of a translator I felt a deep satisfaction. PIH’s efforts in a country with a handful of doctors could not have been launched without people like Zanmi Lasante’s Dr. Jonas Rigodon (who has written in these pages about his work in Nohana). But in addition to the pride we take in South-South collaborations between Haiti and the African sites in which we work, there is satisfaction in knowing that we are also able to reverse, in some measure, the brain drain that has taken so many doctors and nurses away from Africa’s poorer countries. The rural reaches of these countries have never had resident medical professionals: this local brain drain, too, we are seeking to reverse.

Finally, with specimens dropped off in the laboratory for testing, we went to the new PIH office in Maseru. As Dr. Nico sat down in front of a computer, he said something I won’t soon forget: “Doing this work as a doctor up in the mountains makes me feel very lucky. To fight for access to health care for the rural Basotho seems to me to be the best job a doctor could have.”

Being in Maseru also allowed me to meet other new members of the PIH team assembled by Jen. Our other major endeavor apart from the rural initiative has been to introduce to Lesotho a sound prevention and care program for multidrug-resistant tuberculosis (MDR-TB). Although we still don’t have a good sense of just how big a problem MDR-TB is in Lesotho, it’s clearly a significant threat to effective TB control here. And although we’ve had a great deal of experience treating MDR-TB in Peru, Russia, and Haiti, there’s an enormous complication in Lesotho: most patients afflicted with MDR-TB, a lethal disease on its own, also have HIV infection. It’s not possible to tackle one disease without tackling the other. And handling either MDR-TB or AIDS requires a mix of clinical acumen and what are termed “programmatic skills,” which means the ability to strengthen public health programs aimed at both prevention and care. This is complex and difficult work, quite different from stitching up an injured patient. Across the world, few people have the sort of training and experience needed to take on these colliding epidemics.

Spending time seeing MDR-TB patients with PIH doctors Kwon-jeun Seung and Hind Satti brought these lessons home. We were in Botsebelo, a clean and well-constructed facility that will soon serve as Lesotho’s national referral center for MDR-TB and also, we hope, as a national center for training health providers in the effective prevention and care of this disease. Most of the patients we saw had been laborers in South Africa, often in the mines; all but one had both drug-resistant TB and HIV infection. Each of them had been treated previously, often over the course of years, with regimens that would have cured drug-susceptible TB. Some had been treated in South Africa. None had been cured.

This reservoir of “chronic” patients in Lesotho will prove daunting, but the PIH team there, especially Jen, has long experience in seeking to treat chronic MDR-TB patients at the same time that efforts are made to speed up diagnosis and proper care of MDR-TB. Proper care, in this setting, means top-of-the-line regimens that might cure even highly drug-resistant strains, even among patients also afflicted with HIV disease. At the same time, the MDR-TB project will seek to help the Ministry of Health to “retrofit” the country’s network of hospitals and clinics to make them safer for patients and their families. TB is too often an infection acquired within hospitals, clinics, and other congregate settings. More South-South collaboration may prove important in Lesotho: the PIH-Peru team (Socios En Salud) has special expertise in infection control and will be providing technical assistance here; the PIH-Haiti team, as noted, has already made an important contribution to PIH-Lesotho in the person of Dr. Jonas, who in August will celebrate a year in service to the people living around Nohana. He often reminds me that, on our first day in the mountains of Lesotho, in the town of Nohana, it began to snow.

All of PIH-Lesotho will be celebrating a birthday on August 22, when co-workers from Lesotho, Rwanda, Malawi, and Boston join the Minister of Health, Dr. Ramatlapeng, the Clinton Foundation, the Irish Government (which has funded much of our work in Lesotho), and many other partners and supporters in the same town, Nohana. Nohana has been transformed in many ways: the facilities there have been retrofitted for infection control; a new clinic has been built; hundreds of patients with AIDS and TB are receiving world-class care; and tens of thousands have received basic health care services, which in Lesotho often includes screening for HIV infection. All of this has occurred in Ministry of Health facilities.

I will be going back to Lesotho from Rwanda in a few weeks, and I can’t wait to be back here. PIH-Lesotho is in many ways the heart of PIH, no less than Haiti: the people who live here have struggled for centuries to improve their lot and the lot of their children. They have sometimes served larger causes, as have the Haitians: as Haiti supported nineteenth-century struggles against slavery, so too did Lesotho serve as a place in which the struggle against apartheid might survive. And at the end of these struggles, both Haiti and Lesotho have been left with less than was owed them by what should have been a grateful world. But in Lesotho, as in Haiti, the spirit of resistance survives and inspires all of us to move forward against all odds.

[published August 2007]