Sharif's Eyes

By Jon Higgins,
Medical Student.
From 30 Sept 2011.

Eyes. The windows into the soul.

Eyes can betray trust, win hearts, offer gratitude, communicate compassion. Some say they can even smile. The first thing I noticed about 32-year-old Sharif were his eyes. Big, brown, and warm, matched only by his wide, beaming smile after my horribly-accented salaam alaikum. As the attending interviewed Sharif, he reported that he had some difficulty with his eyesight recently, and after consulting an ophthalmologist, was sent to icddr,b's Jagori Unit*. I was observing clinical rounds at the time.

One of the terrifyingly awesome responsibilities of becoming a doctor is the incredible amount of trust people place in letting you intrude their personal space - sometimes to the point of literally going inside their bodies. I am keenly aware of this fact, particularly with my intention to go into surgery.

Days later, Sharif would agree to let me take an ophthalmoscope, place it centimeters from his dilated eyeballs with my face just as close, the bright light blaring directly on his retina, and gaze through the windows into his soul. If I had done it the day he came, here is what I would have seen (it was instead on photo paper he brought with him): [Photo: Sharif's CMV chorioretinitis. Notice the characteristic tree-branching, perivascular pattern on the right eye (left side of image), and the alternatively characteristic exudative "cotton ball" scarring on the left eye (right side of image)][/caption] Thus I learned that Sharif has AIDS. HIV/AIDS is uncommon in Bangladesh.

WHO and UNAIDS estimated that, at the end of 2005, the prevalence of HIV was 7,500 people, <1% of the population. Fortunately, the Government of Bangladesh and international communities have done well in targeting prevention and surveillance programs in high-risk populations in Bangladesh, yet the future of HIV/AIDS in Bangladesh remains to be seen in a low-income country with so many overwhelming issues to tackle. However, such a low detected prevalence does means lack of familiarity of healthcare providers with testing and treatment, little laboratory facility infrastructure for detection of new cases, and sometimes even unfounded stigma from healthcare workers.

And that is why Sharif came to Jagori. You see, the ophthalmologist found CMV chorioretinitis. It is a characteristic infection indicating immunosuppression, meaning you hardly see it unless someone has a trashed immune system such as after a transplant or while receiving chemotherapy (in immunocompetent individuals, CMV is a lesser-common cause of "mono"). But Sharif was not a transplant patient or taking chemotherapy. He had AIDS. The treatment for CMV chorioretinitis is, fortunately, quite simple: ganciclovir. It's a nasty drug with nasty side effects, but it could be done with a much safer intraocular (into the eye) injection once a week as an outpatient. Or we could do it by keeping him uncomfortably in the hospital for many days to give intravenous ganciclovir, subjecting him to an increased risk of serious side effects on his hematologic system (blood cells), and keeping him from his work and his family that depended on every cent he could make.

The options were pretty clear to us. So, why was Sharif here? We provide hospital care, not long-term outpatient HIV therapy, HAART (several NGO partners do that aspect.) The team thus called the ophthalmologist. He was refusing to give the intraocular injections in his office. He wouldn't even come to the hospital and do them, where we would provide the gloves, equipment, and even reimburse him.

An eye doctor refusing to work on a patient's eyes to save that patient's eyesight. Unbelievable. You can read between the lines as to the doctor's main reason. I thought back to the faces of HIV+ orphans in South India who were denied access to over 30 schools, public and private, because of their status. We had shared McDonald's (a luxury there) and many hours holding hands. I recalled mustering strength to look into the eyes of a young widowed mother as the translator relayed her words, that she and her children could no longer eat with their extended family because she was HIV+. I remembered the screams of a young girl as we dressed her burn wounds, a result of a mother's mental breakdown after she had just been diagnosed, already a widowed Dalit single mother now with HIV. Certainly not pleasant memories, from my prior stints in Asia. But real memories. So instead we had to subject Sharif to the latter option. Fortunately, he has been quite chipper and has not had any side effects from the IV ganciclovir. On my last fundoscopic exam, his retinas look much better though his vision, while improving, is still not back to normal. The life which Sharif will lead when he leaves us is a difficult one. Stigma, poverty, further infections from the tiny virus slowly destroying his immune system.

The medical system had come awfully close to failing to provide him respite from any of them. Some stories cannot be left untold. I hope that this can change. There are glimpses of it, and there are many heroes here who sacrifice so much to tackle such pressing problems, like the doctors and nurses on the Jagori ward who take in patients after multiple hospitals - and even NGOs - refuse to take them under their care. I hope to continue meeting them and joining them.

*The Jagori Unit is icddr,b's ward for persons suffering from conditions related to HIV/AIDS. Patients are placed here not to isolate them, but because the clinical treatment of the consequences of HIV/AIDS is unique, requiring familiarity of them with the nursing and medical staff. Thus, placing patients here is no different than placing them on the acute respiratory illness ward or the GI disease ward. Obviously, Sharif is an alias for confidentiality's sake. He gave his consent for me to tell his story and post pictures of his eyes, so that friends and colleagues back home could know what it is like for a Bangladeshi living with HIV/AIDS.