Vaccination

 

Vaccination

It was 1990. I was a house officer, newly graduated from medical school. It was in a teaching hospital in the Northern Nigerian town of Zaria where I grew up. I was asked to admit a very sick 24-year-old man.

He was a used car parts salesman. He was an ethnic Ibo from Southern Nigeria, far from his family, currently working in the North. Over the last few weeks, he had become increasingly unable to hold down food and water. His complexion had become yellow, all pointing to some type of liver disease.

When I examined him, his abdomen felt like he had rocks at the area of the liver. My senior resident was with me and she said simply, this is advanced liver cancer. We cannot do anything for it. We did a further work up on him and found the he had chronic hepatitis B. He likely got this at birth from his mother. This probably caused his cancer. He died 3 days later.

Another person was a colleague and close friend of my father. He was a professor and a PhD from Northwestern University in the United States. He was diagnosed with liver cancer in 1992 and chronic hepatitis B. I remember visiting him as he lay dying in 1992 with my father and his death affected me deeply as I had known him from childhood.

It was frustrating. Mother to baby transmission of hepatitis B is the commonest way of transmitting the virus in endemic areas such as China, the far East, and West Africa. About 90% of exposed babies develop chronic infections. In America, sexual spread amongst adults is more common and only about 15% of these go on to develop chronic infections.

Hepatitis B was first described in 1967 and a vaccination against hepatitis B was first made in 1969 by Dr. Baruch Blumberg at the university of Pennsylvania. He was given a Nobel prize for this in 1976. The first commercial vaccine became available in 1981 and a synthetic vaccine approved in 1986. I remember getting a version of the vaccine as a trial when I was a medical student in Africa in 1987.

 These earlier vaccines had a mercury-based preservative called thimerosal. Some linked this preservative to autism, although research has shown there is no link. Thimerosal has been removed from all US vaccines since 2001. Universal vaccination for all babies against Hepatitis B was recommended by the CDC in 1990. This has dramatically reduced the incidence of Hepatitis B in the younger population in the United States.

However, on December 5^th, 2025, in the United States, a hand picked federal advisory committee on immunization changed the recommendation against universal vaccination of babies against hepatitis B. This was under the influence of the secretary of health who is against vaccines despite having had no medical training or experience.

 I felt very sad at this news. I still vividly remember the faces of the people I have seen die from hepatitis B induced liver cancer. The vaccine is extremely safe and could have prevented those deaths, had it been available at that time.

 It will take many years for us to see the effects of these changes amongst the population. Of course, by then it would be too late for some. I hope I never have to see that look of desperation and hopelessness that I have seen in the young people who developed liver cancer from chronic hepatitis B.

 

Hepatitis B vaccination in a child

 

The Three Rings

 

The Three Rings

 

Recently I was seeing a patient of mine. She was in her early seventies and was quite healthy. She was always cheerful with a smile on her face. I loved her positive attitude and we had a great visit discussing her preventive care. Towards the end of the visit, I noticed the necklace she was wearing. It was three intertwined rings, each with a name on them. I said to her that this is very nice and asked her if those were her children? She said yes, those were her three children. I asked her if they lived nearby. She looked at me and said in a very matter of fact way, “no, they are all dead”!

 I was greatly taken aback. I asked, what happened? She replied – her daughter was in her late twenties and married with children. She developed gall bladder problems and had to have surgery. This surgery was botched according to her and her daughter died. The grandchildren went with their father and she has not seen them since. She does not know where they live. Her older son was killed in a car accident also in his twenties. The youngest son got married and had a son, but at the age of 48 he had a heart attack and died. His son is the one grandchild she is still in touch with. Today, she herself lives with her husband. He gave her the necklace in memory of their children.

 She spoke to me about her husband and the wonderful relationship she has with him. She told me that they have been great support for each other. She also told me that she takes comfort in the fact that she will be reunited with her children one day.

I have seen many patients who have lost children. Many are older and in the late stages of their lives. I usually sense the existence of significant grief and a common hope that they will once again meet their children after they themselves die.

 I reflected a lot on my patient's journey in life. What impressed me the most was her positive attitude and cheerful nature. There is a lesson I learnt here. Life may give us setbacks and tragedies, but it does not stop us from looking at the positives we have and maintaining a good attitude. I am grateful to my patient for teaching me this.

The Export

The Export

I got a message the other day informing me of the death of one of my patients. This was unexpected. He was mostly healthy, in his early 70’s, but had recently developed an infection. As part of his recovery, he had been in a rehabilitation home. His wife told me that he had actually been doing quite well the day before, but in the morning he was found to have passed away in his sleep.

I was deeply saddened by his death, but did my best to comfort his wife. As with most of my patients, I had developed a relationship with both him and his wife. He had led a fascinating life. This is his story.

He was born to a father who was a professional golfer. As he grew up, he took up playing golf. He however could not make it as a professional golfer. He then gradually got involved in helping to build golf courses. In particular, he developed an expertise in using a bulldozer to help shape the golf course grounds.

He joined a golf course construction company. The golf courses would be designed by an architect, and he would lead a team to bring the architects vision to life. He was involved in building many golf courses in the United States.

He then came to me one day and told me that he will be away for several months as his company had got a contract to build golf courses in China. I was taken aback? Why China? Apparently with the new found prosperity in China, golf is becoming more popular. Many golf courses are being built and American companies are the best in the business. They take their own crews who work with local groundsmen to build the courses.

The company would arrange for apartments for the American crew to live in at the site of the golf courses. Most of these golf courses were in relatively remoter locations that foreigners do not typically go to. He told me that cuisine was often a challenge as American food was usually difficult to get. His wife would be with him. I had to ensure that they would have their prescriptions filled for six months at a time before their trip.

He built many golf courses in China and other nearby countries such as South Korea until he retired. He would see me for his medical appointments during his visits home and share with me some of his experiences.

Interestingly, I was watching the news about how America has a large negative trade balance with China and imports all kinds of goods from them. However, in terms of golf courses, it is the other way around.

I hope my patient is now at peace at a golf course in heaven. 

The Lost Boy

 

The Lost Boy

It was 2003, and I was doing a fellowship in Infectious Disease. As part of the training, I was in the Infectious Disease clinic one day. A patient showed up with an African sounding name and the reason for the visit was listed as ‘Leprosy.’ I was intrigued. I had grown up in West Africa and seen a fair amount of Leprosy there. I went in to see the patient. He was a young man, tall and dark. He was from the Dinka tribe of Southern Sudan. He did not speak English but had a friend as a translator. He had successfully completed his treatment for Leprosy and was cured. He however also had HIV but was well controlled on treatment. He was doing well, and I completed my visit.IV and was well controlled on treatment

Later, when I was discussing the visit with my attending, he asked me if I knew anything about the ‘Lost Boys of Sudan?’ I had heard the term, but did not know the details. He then told me that the country of Sudan in East Africa had a civil war. The Second Sudanese Civil War was a conflict from 1983 to 2005 between the central Sudanese government and the Sudan People's Liberation Army. It lasted for almost 22 years and is one of the longest civil wars on record. The war resulted in the independence of South Sudan six years after the war ended. Roughly two million people died. Four million people in southern Sudan were displaced at least once, normally repeatedly during the war. 

Many children were orphaned or separated from their families because of the systematic attacks of genocide in the southern part of the country. Some children were able to avoid capture or death because they were away from their villages tending cattle at the cattle camps and were able to flee and hide in the dense African bush. Children were highly marginalized during this period. As a result, they began to conglomerate and organize themselves to flee the country and the war. Motivated by the loss of their parents and their need to find food and safety from the conflict, an estimated 20,000 boys from rural southern Sudan (mostly Dinka and Nuer tribes) fled to bordering Ethiopia and Kenya.

Much of the travel took place by foot in large groups with the boys traveling in single file lines. The journey from South Sudan to the nearest refugee camp could be up to thousands of miles. Travel ranged from a span of weeks to two or more years. Often, the children traveled with no possessions besides the clothes on their backs. The Boys often depended on the charity of villages they passed for food, necessities, and treatment of the sick. Groups of Boys were often organized and led by the oldest boy in the group, who could be a young adult or sometimes as young as ten or twelve years old. Some made it to refugee camps in Ethiopia and Kenya. The name "The Lost Boys of Sudan" was given to them by workers at the refugee camps.

In 2001, as part of a program established by the United States, and the United Nations High Commissioner for Refugees (UNHCR), approximately 3,800 Lost Boys were offered resettlement in the United States with assistance from charities in the United States. They are now scattered over at least 38 cities, including major metropolises such as Chicago, Dallas, Boston, Seattle, and Atlanta. Halted after September 11th for security reasons, the program restarted in 2004. As of 2006, the largest population of these refugees in the United States was in Omaha, Nebraska, which hosted about 7,000 people. 

Our patient was brought over by the Lutheran Church. He did not have the health screenings that most immigrants get prior to coming and was found to be positive for HIV infection on arrival in the United States. He was started on treatment and was doing well but then developed an anesthetic spot on his arm. This was biopsied and found to be leprosy. He was started on treatment and sent to one last remaining Leprosy treatment center in Louisiana.

My attending then told me the story of trying to get him on a Delta flight to Louisiana. He said, it was difficult to convince the airline that this patient had active leprosy but was not a risk to the other passengers. He had to write official letters to convince them.

Many of the lost boys had difficulty assimilating in America. A large number had post-traumatic stress disorder. In January 2011, 99.47% of South Sudanese voted to separate from the north and become an independent nation. Some American former Lost Boys now hold positions in the current government of South Sudan.

My patient had appeared to be doing well, despite his inability to speak English. I hope he continues to do well today.