Extreme medicine


Yvonne Maldonado, MD, associate professor of pediatrics at Stanford, knows firsthand the enormity of the health crisis among women and children in sub-Saharan Africa, as she’s spent several weeks every year for the last six years in Zimbabwe working on HIV prevention.

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In a country of 20 million, some 20 percent of pregnant women are HIV-positive, she says. She and David Katzenstein, MD, professor of medicine, have been testing the long-term use of the antiretroviral drug nevirapine as a way to prevent mother-to-child transmission via breastfeeding. Of those who escape infection at birth, as many as 10 percent acquire the virus through breastfeeding, says Maldonado, a specialist in pediatric infectious disease who works most of the year at Stanford University and Lucile Packard Children’s Hospital. She and her colleagues soon will test the value of the drug in 1,500 mothers and babies in Tanzania, Uganda and Zimbabwe.

As she travels between Palo Alto and Africa, Maldonado says she finds the disparities in medical care jarring. “I go from one extreme to the other,” she says. “Here we are just putting the finishing touches on prevention of perinatal HIV infection. Over there, we’re just trying to get people into treatment.”

Mark Ghaly, MD, a general pediatrics fellow at Packard, also has found a whole new world of challenges in Uganda, where he spent two months last year treating children with HIV. Not only is there a shortage of resources in Uganda, but also huge gaps in knowledge on how to treat children and a lack of collective experience and information-sharing among practitioners, he says. In one case, he says, two girls came in with serious neurologic complications, but the clinic had money for only one CT scan. “I thought, oh my God, you’re kidding me, I didn’t know which one to pick. It was surprising to me that somebody there wasn’t better-suited to make this decision.”

Ghaly also worked with Ugandan social workers on how to tell children they’re HIV-positive. “In the pediatric world, it’s a challenge to come up with guidelines on how to socialize kids with HIV, how to disclose the diagnosis, how to prevent the victimization and the stigma… .The kids who know they are HIV-positive are depressed, and there are no resources to help them. It’s a huge, huge issue.”

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