Interview with Laura Pomeroy

“I'm currently working as a field nurse in an MSF HIV treatment centre in the city of Nanning, southern China. Its quite an unusual project for MSF in the sense that it’s not at all like our work in very poor places like Congo and Darfur – Nanning city is quite developed and the standard of living here is relatively high. The aim of the MSF programme is to provide high quality treatment for HIV/AIDS patients - that means not just handing out anti-retroviral drugs and sending patients away, but providing more comprehensive care. For example, we advise patients on how to take their drugs properly and educate pregnant mothers about how they can guard against the HIV virus being passed on to their babies during childbirth. In fact, many people don’t realize that giving free treatment is only a fraction of what an HIV programme should be about.

Tuberculosis (TB) is something we have to deal with on a daily basis, since about a third of our patients have the disease and a significant number die from it. That’s because TB is one of the major ‘opportunistic infections’ which HIV positive people are highly susceptible to. Tuberculosis is an airborne disease that is transmitted when a person breathes in the bacteria from someone who is infected. Many people here, especially the large migrant population, live in very basic conditions with lots of people living very close to each other. In these conditions, TB can easily spread.

Treating people with TB in China is quite a challenge. China's health system seems to have all the gadgets and expensive equipment, but little know-how when it comes to TB and we see many patients who have been poorly managed in other hospitals. We often find it hard to convince local doctors of the importance of carrying out ‘sputum’ tests in order to diagnose the disease. On top of that, pills which combine several TB drugs in one tablet - known as ‘fixed dose combination drugs’ – are not available in China, which means that some patients have to take up to 17 separate pills every single day for two months at the beginning of their treatment. We also fear that a lot of patients could become resistant to both first and second line treatment – what is known as ‘multi-drug resistant’ (MDR) TB. Unfortunately, for them its pretty poor prognosis. That’s why we plan to investigate this problem, in order to have a better picture of it.

There was one man who came to us who was transferred from the local hospital and looked just painfully thin. His sister was the main breadwinner of the family and she was looking after two of her brothers who were both sick. With no social welfare this girl was desperately trying to work and support her brothers at the same time. She used to carry him in everyday on her back and give him the injections at home herself, as well as making sure she that he took his tablets right. Very sadly, he died. It was an extremely sad example of how TB can kill when it is not properly managed - people unfortunately come to us too late and have a really sketchy treatment history - they’re just too wasted and beyond help.

This is my first mission with MSF - I was working on HIV research in a big London hospital before I came here last October. As a nurse, its quite nice working on TB, because it’s something I can really get my teeth into. Generally, nurses don’t really play a big role in China, but with TB there is a lot for us to get involved in, both in terms of working with the doctors and communicating with the patients. If the doctors suspect a patient has TB, they are sent to us for three ‘sputum’ tests. We have to explain very carefully to the patient what we need from them – basically they have to produce yellow mucus from their lungs to be sent to the lab for analysis. It takes quite a lot of work to get them to produce a good sample rather than watery saliva. We get them to take in big deep breaths and then get them to cough and if that doesn’t work it sometimes helps to ask them to imagine steaming up a window. There are lots of cultural aspects to bear in mind when you are dealing with patients, because their fear of being stigmatized is very strong.

We also give basic counseling and advice to patients when they are first diagnosed with TB. For example we tell them to cough or sneeze into a tissue - which isn’t very Chinese -, to wash their hands, to ventilate their houses well and to avoid spitting in order to protect other family members. We also explain the importance of taking their medication everyday in order to avoid becoming resistant to the treatment. We see new patients every week for the first month of treatment and we count their pills to check that they are taking them right. People tend to be really good at taking their drugs, although some of our patients - about 20% - are intravenous drug users who tend to lead more chaotic lives and will suddenly decide to stop taking their medicine for a couple of weeks. They are more of a problem group, and if we think that someone is not taking their medication properly we give them extra counseling sessions so that they really understand how important it is.

HIV positive patients are heavily stigmatized and discriminated against in China – even the hospital charges HIV patients extra for the cost of burning the sheets that they have slept on. A lot of health staff are scared. An MSF nurse has now done quite a lot of workshops in the local hospitals about how to guard against HIV transmission, so I think the level of understanding is a bit better now. There is also a lot of fear in the communities and HIV/AIDS is certainly not talked about - quite a few of our patients choose to come from other towns to the MSF project because they don’t want to be seen in their local community attending an HIV clinic. That’s not unusual – in fact, the same thing happens in London. People ask us things like whether it is OK to eat with their HIV positive family member. A lot of our patients choose not to tell their families, so they are in it alone, with no support, which is very tough for them.

My job here is very different to what I was doing before as a nurse in the UK - I can be much more inventive here in terms of throwing in ideas about how to improve things, which is quite different from working in the NHS where you are just a tiny cog in a huge wheel. Ihave a broader role here – I’m part pharmacist, I do dressings, I do admin. I’m the only expat nurse, and together with a Chinese nurse I’m in charge of seeing the patient all the way through the treatment and making sure that all the tests are done at the right time. So in many ways it’s very rewarding."