Wednesday, March 23, 2011

Two Scratches of a Pen

The crumpled piece of yellow paper at my foot caught my eye. I bent over to pick it up. Then halted.

A flimsy piece of trash. Worthless. Discarded. Smudged. Walked upon. Crumpled. With the vague ink stamp of our clinic visible in the bottom left corner.

And above the stamp...a life altering scratch of an ink pen. A plus sign. Positive.

HIV positive.

With two scratches of a pen, a life altered for its duration.

I picked up the paper, quietly folded it, and stuck it in the back pocket of my scrubs.

Of course, I know this patient. I know this paper. Discarded trash from yesterday. That was my writing. A lab order for the cachectic, febrile twenty year old girl from a tent city. I'd ordered that test. I'd passed the paper to Sister Gloria, our nurse, and requested her to run it. She returned to me thirty minutes later, and with a stoic, kind-yet-grim look in her eyes, handed me back the slip. I'd met her eyes in silent, knowing, communication.

Two scratches of a pen. A life altering diagnosis.


The twenty year old girl, skin and bones, laid curled on her side in the next room of the clinic, staring blankly at the wall. A resident of one of Haiti's semi-permanent post-Earthquake tent cities. Mother of a 6 year old child. A quick calculation revealed she therefore became pregnant at 13 years old, and gave birth at 14. She breathed rapidly. She was fragile. Like a small bird, fallen from her nest.

I walked into her room, and through a translator, revealed her test results. "Your HIV test is positive," I explained. "This means you likely have HIV, the virus that causes AIDS. We need to confirm this with another test. But I am very concerned."

She stared blankly at the wall.

"Do you have a sexual partner?" I asked.

"No," she replied. "Not since I got pregnant."

Another simple calculation. Last sexually active at age 13. Therefore, HIV positive at age 13.
Now, likely, AIDS. At 20 years old.

"Did you get tested for HIV when you were pregnant?" I asked.

"No," she replied. She got no prenatal care at that time. At 13 years old.

"Did you breastfeed your baby?" I asked.

"Yes," she replied.

Another mental calculation. Untreated HIV positive mother, never diagnosed or treated, subsequently breastfeeding her infant. Means child at risk for "vertical transmission". Transmission of HIV from mother to child, either at birth, or subsequently through breast milk exposure.

"We need to get your daughter tested for HIV, too," I said quietly. Mother stared blankly at the ceiling. The implication, and subsequent palpable self-accusation, was strong. The risk to her daughter's health. A mother's guilt. Finally, as the information was slowly absorbed, a quiet nod. Empty staring eyes.

I flashed mentally to the World Health Organization recommendations for HIV prevention. The "ABCs" of HIV prevention in sexual relationships:

A = Abstinence

B = Be Faithful to your Partner

C = Condoms

I suddenly remember the semi-angry rant of one of my Tropical Medicine professors -- an HIV and TB expert from India, who spent many years as a physician in the urban public health trenches before becoming a professor at Tulane. To paraphrase her highly-educated and evidence-based rant, in response to the ABCs:

Don't think that women of the developing world aren't aware of how they get HIV and AIDS. They know. They are not ignorant. They know about AIDS and know that it is sexually transmitted. The bigger issue is the ability of a woman to say "no". In many parts of the world, due to imbalances of power in the role of men and women, women have no power in a sexual relationship. Whether it is through physical dominance, or financial dependency. They do not have the social power to refuse sex. They do not have the social power to say no, to demand condom use, nor to demand monogomy of their husband/partner.

I look back at my patient, pregnant at 13 years old.

Infected with HIV. At 13 years old.

Was that sexual relationship an educated choice? Or any sort of choice?

At 13 years old?

In Haitian post-earthquake tent communities, where some estimate HIV rates could, in some, be as high as 15%, rape is on the rise. One recent news article reported on the experience of a middle aged woman, who came upon a teenage girl being raped by a group of young men behind a tarp dwelling. She began screaming at the men, physically trying to pull them off the girl. The men turned upon her, and gang raped her as well.

"Why did you try to help this girl?" asked the reporter. "Weren't you afraid?"

"I have a daughter her age," replied the older woman. "All I could think was, if it were my daughter, I would want someone to help her."

Emergency surgery was required to save the older woman's life...from hemorrhaging....from the injuries sustained during her gang raping. Trying to save an even more powerless woman from sexual assault.

I stared back at my patient.

Like the paper I found at my feet today...

A crumpled, discarded, treaded-upon form. A tragedy.

Haiti has the highest rate of HIV in the Western Hemisphere. 2.2 percent of the population -- more than 1 in every 50 persons -- has HIV.

How do we stop this epidemic?

Increase access to healthcare.

Reduce poverty.

Promote safer sexual practices.

Empower women, first through education. More power naturally follows.

Fund education for all.

Work to remove the social stigmas associated with the diagnosis of HIV.

Is this an impossible task? No.

Start with you.

And not just in Haiti.

Start with you. Start with your community. Your children. The young women and young men in your life. And the older women and men in your life. Teach abstinence. Teach faithfulness. Teach condom use. Teach respect. For self. And for others. Encourage the education of girls. And boys. Encourage the human rights of girls. And boys.
Get tested for HIV. Encourage others -- especially those you love -- to get tested, too.
There are 33 million people in the world with HIV today. Nearly 2.5 million more will acquire HIV this year. And an expected 2 million people will die.
Lives transformed, with two opposing scratches of a pen...


  1. I really enjoy reading your blogs. You're very good at putting your experiences into words so that others feel like they are also slightly experiencing it. Also, I like the note about the professor because I remember when she had that rant. Very cool. Hope things are well. Bonnie and I miss you dearly.


  2. I wish everyone on the planet could read this. I'll share...

  3. This is powerful. One thing that grieves my heart so much is the number of women and children who face terrible consequences for decisions not their own.

    Is there any hope of educating men and bringing change to their perspective on the world? Or is it just too engrained?

  4. This is all a heart-breaking reality around the globe. It hits close to my heart/home, it hits close to everyone. God bless you for these words and your suggestions for action..Just a woman who loves..Namaste

  5. Powerful amen.
    Cheryl RN