“We had a three-month-old child who was struggling in the pediatric wards. He was getting concentrated oxygen, but it was being split among him and two other patients. His saturations were around 70% (far below healthy levels of 92% and above), and he was working really hard to breath. We transferred him to the pediatric ‘High Dependency Unit’ thinking that he could get his own oxygen there. But when we got to the HDU, we found that only two of the four oxygen concentrators were working. Two had been broken for so long that the nurses had stopped trying to fix them. There are five beds in the HDU that are always occupied with the sickest patients. Even where we usually house the sickest of the sick, we are limited by lack of oxygen. I spent the next two hours searching the rest of the hospital for concentrators and making back-room deals with nurses. Finally, I found an extra concentrator in the adult HDU, but I had to promise we would return it by the end of the week. We brought the oxygen concentrator back to the pediatric HDU. When we placed the child on his own concentrator, his oxygen level shot up to 93%. His breathing slowed, and his pale blue skin turned a healthy pink. That is a typical half-day at Kamuzu Central Hospital: Looking for oxygen. A few days later, we had to switch our patient to a shared concentrator so that a two-week-old infant could have the unshared concentrator. Our patient died shortly afterward. When I came into the HDU and found out what was happening, I asked the nurse what she thought she was doing. But then I realized: What else could she do? There just isn't enough oxygen to go around, and she chose to give it to the two-week-old who needed it more. These are the tragic choices we have to make in this setting. But it doesn’t have to be like this.”

Andrew Smith, M.D.

“In August 2008, Dr. Eric [McCollum] and I took care of a teenage patient on the wards named Chisomo. She had horrible lung disease: on top of overall malnutrition, we were treating her for tuberculosis, bacterial pneumonia, PCP pneumonia (a fungal pneumonia that indicates very advanced HIV infection), and lymphocytic interstitial pneumonia (another indicator of advanced HIV). She was so sick that one of her lungs collapsed twice. For over a month, Chisomo had very labored breathing, with a respiratory rate about four times a normal rate and chest indrawing and grunting—all signs of respiratory distress. I never thought she would leave the hospital alive. However, we managed to keep her alive with concentrated oxygen (though she often had to share her concentrator with several other patients, which diminished the amount she received). Once she was healthy enough to begin antiretroviral therapy for her HIV, she recovered quickly. She recently visited us and is happy, healthy, gaining weight, and even playing net ball at school without any further respiratory problems. It’s truly amazing to see how much better she is now.”

W. Chris Buck, M.D.

Dr. Chris with happy, healthy Chisomo.

“A seven-month-old boy named Chimwemwe [Chichewa for “Happiness”] was suffering from very severe streptococcal [bacterial] pneumonia and likely pneumocystis [fungal] pneumonia. Despite being on concentrated oxygen, the oxygen level in his blood was a mere 74% (acceptable levels are above 92%). When we investigated why his oxygen saturation remained so low, we discovered that he was sharing his concentrated oxygen with six other patients! We tried to find other available oxygen sources for him, but to no avail; the remaining concentrators were either non-functional or were being shared by four to five other children. We transferred Chimwemwe to the ‘High Dependency Unit,’ where one oxygen concentrator was available just temporarily, as a post-surgical patient was coming within the hour and would need both the bed and the oxygen concentrator. When placed on this oxygen concentrator, Chimwemwe’s oxygen level immediately improved to 95%, because he was not sharing it with other patients. Unfortunately, we had to switch him back to the shared concentrator when the post-surgical patient arrived. Chimwemwe died the next day.”

Eric McCollum, M.D.

Above: Chimwemwe, pre-hospitalization. Below: Chimwemwe, hooked up to concentrated oxygen in the High Dependency Unit, where an unshared oxygen concentrator raised his oxygen level by more than 20% – until he was returned to a shared concentrator.

“The number one cause of death in hospitalized infants and children throughout southern Africa, regardless of HIV status, is respiratory failure. In my brief time at Kamuzu Central Hospital, there were many children who had PCP pneumonia, atypical pneumonia, tuberculosis, asthma, malaria, anemia, and lymphoid interstitial pneumonitis. I recall one girl who had a collapsed lung (as a result of tuberculosis) for almost two weeks while she waited for a chest tube to arrive. She, along with many of the other children I saw, would not have made it out of the hospital alive without concentrated oxygen. In the United States, I had taken for granted the effectiveness of oxygen; it is universal standard procedure for patients with respiratory illness. Working at Kamuzu Central Hospital showed me why. Each concentrator, when it is working properly, can supply three children. I saw great success with these machines—when they worked. In the children’s ward, one of the machines never worked, one could only produce oxygen for one person (instead of three), and the last one worked only on occasion. Many children were saved when the concentrators were working, but often they didn’t work at all. One of the most difficult things a clinician will ever have to do is triage [i.e., decide where in the hospital to send] a child to live or possibly die based on the fact that there is not enough oxygen for everyone. The need for new, functional oxygen concentrators at Kamuzu Central Hospital is huge. Too many children are dying because of the failing concentrators that are there now. Each new oxygen concentrator has the potential to save hundreds upon hundreds of lives.”

Garrett Soames, P.A.-C., A.T.C.

An oxygen concentrator in Children’s Ward A, split three ways.

“I took care of a lovely 14-year-old by the name of Tabitha. She had been treated for many years with multiple courses of TB medication, but in the end she was found to have chronic lung disease resulting from HIV. Her lungs were full of cavities and collapsed. She would present to the hospital every few weeks in severe respiratory distress, blue, and with oxygen saturations around 60%. Her face would be desperate with the lack of oxygen, swollen, and her heart on the verge of collapse, having to work hard to compensate for the low oxygen levels in her blood. We would start antibiotics and put her on oxygen and within 24 hours she would be smiling and pink again. We would tune her up as best we could and send her home, but realized that she was coming in more and more frequently, almost every week, for oxygen therapy. Soon it was impossible to get her off oxygen; her collapsed lungs just could not function on their own. So the dilemma was how to get this girl home when she needed chronic oxygen therapy. She knew she had HIV, and she knew that she was dying. She talked very openly about it, and stated that her one wish was to go home and spend time with friends. She wanted to die at home, surrounded by her family and not in the crowded, hot, noisy hospital ward. Luckily, we had an extra oxygen concentrator on the ward. Although we could have put it to good use there, we decided this was an opportunity to give a beautiful little girl the time she needed to say goodbye to her loved ones and make the last moments of her life as full as possible. The family had electricity at home, so we set up the concentrator for her at her house. Due to the constant oxygen therapy, she lived another four months at home (we had expected only a few weeks!), and her mother says they were four of the best months of her life. When she died, she was at peace. It was really a miracle she lived so long, and it was due only to the oxygen concentrator we were able to give her what she wanted most: a somewhat normal life at home.”

Janell Routh, M.D., M.H.S.

Tabitha, on oxygen.

“You didn't have to be a doctor to realize that PM was in trouble. At age 14, a normal rate of breathing is about 20-30 breaths per minute. PM was breathing at a rate of 80, deep and labored. And you didn't need advanced technology to know that the level of oxygen in his blood was critically low, because his lips were blue. But worse than his labored, fast breathing or blue lips were his eyes. He was old enough to know something was very wrong and young enough to be very scared. I'll never forget the way he looked at me, saying ‘please help me,’ without actually saying it. He desperately needed oxygen because of a common but devastating lung infection in children infected with HIV, but he was unlucky. The hospital, as always, was very busy and of the few oxygen concentrators in the hospital, two of them were not working; the others were already occupied by similarly sick children. How do you take oxygen away from one child who needs it to give to another who needs it? It is a dilemma that occurs literally every day in the Kamuzu Central Hospital pediatric wards. For PM, and for the majority of children needing oxygen, what usually happens is that oxygen from one concentrator is ‘shared’ between multiple patients, rendering it less effective, if effective at all. However, this is the only currently available option. There is a great need for more oxygen concentrators, and PM needed one that day. The following morning I found his father standing next to his bed, holding PM’s lifeless hand. I looked at the father and told him his son had passed away. He told me he knew; he had seen him get calm and stop breathing 5 minutes prior to my arrival. I told him I was sorry. He told me, ‘It happens,’ a tragic truth so fitting in Malawi that these words have become a common saying. What I wanted to say, but didn't, is, ‘It doesn't have to happen.’”

Jeff Robison, M.D.

The Baylor College of Medicine/Abbott Fund Children’s Clinical Centre of Excellence (COE) is a pediatric HIV/AIDS clinic located on the campus of Kamuzu Central Hospital in Lilongwe, Malawi. It is part of the Baylor International Pediatric AIDS Initiative network, which currently operates in nine countries worldwide. The COE is staffed by ten doctors from the United States, one of whom is permanently assigned to the children’s wards of Kamuzu Central Hospital and is typically joined there by at least one other physician, as well as a Baylor clinical officer and nurse. The wards are an important point of care for the COE’s sickest patients and also one of the COE’s biggest sources of newly identified HIV-infected patients. The initiative to bring new, functional oxygen concentrators to the wards will improve health outcomes for COE patients and for all other children treated at Kamuzu Central Hospital.