Quotes of the Day

"It's time for... Jeopardy! And here's your host — okay, so it's not Alex Trebek, but please welcome Dr. Tony Garcia-Prats, a fourth-year resident at Baylor College of Medicine! And your categories today are — Outbreak, the Not So Love Boat, It's a Stretch, Something's Fishy, and, last but not least, Love Boat Trivia. Are you ready to play?"

The 52 doctors crowded into the small conference room in Houston certainly are. They're having a bit of fun in the middle of an intense four-week crash course in tropical medicine. At the end of their medical marathon, they will be trading the steamy urban comforts of Texas for the hothouse that is Africa; some are headed to the southern tip of the continent, to Lesotho, Botswana and Swaziland, others to the west, to Burkina Faso, while another bunch is destined for the east, to Malawi and Tanzania. Before they go, however, they need to learn an entirely new kind of medicine, and become familiar with parasites, pests and pustules the likes of which they have never seen in their few years as doctors. The Jeopardy game is the Lesotho group's creative way of injecting some entertainment into the classic medical school teaching tool — the case study.

The man responsible for turning these urban docs into developing world saviors is Dr. Mark Kline, director of the Baylor International Pediatric AIDS Initiative (BIPAI). An affable, Ed Harris look-alike, Kline is the mind, body and soul of BIPAI. He is responsible for creating the Pediatric AIDS Corps (PAC), an innovative, Peace Corps-like program for U.S. doctors interested in treating children with AIDS in the developing world, where over two million kids are currently living with HIV.

According to the latest figures released by UNAIDS last week, 530,000 children under the age of 15 contracted HIV in the past year, most from their HIV-positive mothers who pass along the virus during birth. With their first breath, these children are born fighting for their lives. And while ever more life-saving antiretroviral (ARV) drugs are moving into places like Africa, thanks to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund, there just aren't enough doctors in these regions familiar with treating kids to use these drugs properly.

"Simply stated, pediatric HIV care was not happening in Africa," says Kline. "One of the major barriers today to scaling up programs for children is that there aren't doctors there who know about the care of children; they don't have the experience caring for children, for dosing ARVs, and for handling side effects." After learning that only five to seven percent of AIDS-affected children are actually receiving drug treatments for their disease, Kline partnered with the Bristol Myers Squibb Foundation in 2003 to build and operate the first dedicated pediatric AIDS center in Bostwana. "I thought, five to seven percent is lousy, it's nothing to be proud of," says Kline.

This year, PAC doctors are deployed to six centers around Africa, and their goal is nothing less than to work themselves out of a job. "The PAC is a bridge program," says Kline. "If we have an American Pediatric AIDS Corps on the ground ten years from now, we haven't done our jobs." Nobody knows better than these doctors themselves that they are only a band-aid, a temporary solution to the more insidious problem of the weak health care system in Africa. The U.S. doctors are charged with treating children urgently in need of ARV care, while at the same time training and teaching local doctors and nurses how to adjust doses and understand symptoms of AIDS in the disease's youngest patients. It hasn't been easy, but the 52 doctors who left Houston in August have been doing their small part to treat as many HIV-infected kids as they can — and to help these kids to grow up in a world that understands and accepts them as no different for the HIV status.

But for the moment, the stigma and misunderstanding about the disease still runs rampant even in capital cities in Africa. That makes it a wrenching adjustment for these doctors, who come from the relatively open society of the U.S. to the more culturally restrained and hierarchical structure found in traditional African nations. When they landed in Africa this summer, the doctors came prepared for the tough questions about drug regimens, and they were primed to talk about the importance of adhering to the drug dosing schedules. But most couldn't begin to appreciate how the very fabric of the new societies in which they found themselves would be working against them.

"I did not realize how much women lack basic rights in this country," Julia Kim writes in an e-mail from Swaziland. "The lack of women's rights has greatly impacted the HIV epidemic here. The only property that a woman legally owns is whatever she has purchased with money that she has made on her own. But when speaking with women in Mpuluzi [a small town in rural Swaziland, close to the western border], many of them told us that whatever money was made from basketweaving was taken by their husbands."

This lack of basic rights trickles down to the children who are often under women's care. "I saw a nine-year-old girl, who had just tested HIV-positive two weeks ago," continues Kim. "I had never seen a CD4 count so low; I could not believe she was still walking without blatant evidence of infection. I tried to impress upon her father the urgency of the situation, the full import of such an immunocompromised state, the dire need for ARVS, urging him to return as soon as possible for adherence counseling with a second caregiver. His response and reply shocked me. There is no hurry, he tells me. I need to wait. He will return when he is ready. There is no emergency. I was sensing defiance in the tone of his voice — that he is the father, and he will be the one to call the shots. I have not seen her again. For some patients, we are too late."

Dealing with the still rampant stigma over HIV remains a challenge as well. "The nurses scold me for 'talking too loud about HIV' while I'm [on rounds seeing patients]," Sarah Kim writes a month after arriving in Lesotho. "Sometimes I feel like saying, 'well the majority of this ward is positive so we have to talk about it!' But I realize that I shouldn't."

Not having the basic medical equipment and medications that Western doctors take for granted is another adjustment. Even in the Centers of Excellence, which represent the higher end of medical care available in Africa, supply chains aren't always reliable. "There are still many challenges here with labs and medicine — not ARVS but things like iron supplements or antibiotics like penicillin that are not consistently available," Megan Harkless e-mailed last week from Botswana. "There is still stigma and fear, and families that are financially very limited with no [electrical] power and therefore no refrigerator. Some patients have to travel for several hours or even an full day to come to Gabarone for clinic visits, many are struggling just to have enough nutritious food to eat."

In spite of — or perhaps because of — all the obstacles, the American doctors relish any small victory that validates their presence. Annu Goel, who is working in Lesotho with her husband, writes about a six-year-old boy who was brought to her at the most advanced stage of AIDS. "He was malnourished, had pneumonia, a big belly — he looked sick," she writes. "But mainly, what stands out is that he is sad. He is ALWAYS sad. One of the doctors here said she did not have a good feeling that he will make it. He has had side effects to a log of the meds. When I first saw him, I told him and his father that he will play and have fun again. I had my doubts — until last week. [After being on a different combination of drugs], his CD4 count shot up and his family and I have hope. He still hasn't smiled, but I have hope."

And that, after all, is a big part of what these patients so desperately need — and what these doctors provide.

To learn more about the Pediatric AIDS Corps, visit bayloraids.org

• Alice Park