Healing African hearts

For many people, the word 'scientist' conjures up images of dead serious guys - and gals - in white coats. Facts, figures, test tubes and graphs: no soul or heart. NATASHA BOLOGNESI paints another picture.

When he was 16 years old, Professor Helmuth Reuter did not know whether to be a preacher or a physician.

Propelled by a desire to do something for the poor, and with a sneaking suspicion that he would have made a frustrated man of the cloth, he finally chose medicine.

Prof Reuter, who is now based at Tygerberg Hospital in Cape Town as director of the Ukwanda Centre for Rural Health, is adamant that his heart - and his future - are deeply rooted in Africa and the plight of its people. It is for this reason that, after three years' specialist training in the United Kingdom, he returned to South Africa and Tygerberg Hospital in 1995.

The following year he joined the Cardiology Unit, where the damage wreaked on the heart by the HI-virus was painfully written on the faces of the many patients he saw every day.

Moved and motivated, Prof Reuter decided to address the deadly relationship between the virus and the heart in detail. In 1997 he was employed as a consultant and specialist and began to exercise his compassion and skill in earnest through his chosen field of research: HIV-related heart disease.

There are several forms of cardiac complications that go hand-in-hand with HIV infection, but in southern Africa the most common and life-threatening of these is tuberculous effusive pericarditis, or TB pericarditis for short. (TB manifests itself most commonly in the lungs, but can affect other organs such as the heart.)

Prof Reuter completed intensive research on TB pericarditis in both HIV positive and negative patients between 1996 and 2003. His work, which was in part funded by the Medical Research Council of South Africa, highlights the challenges doctors face in the diagnosis of this cardiac complication, and also the relief that care brings to patients.

Helmuth first met 'BB', a 23-year-old woman, in the admissions room of the cardiology ward at Tygerberg Hospital in 1998. 'I remember her so clearly,' he says, 'because she wore a face of utter hopelessness.'

BB was HIV positive and convinced she had TB. She was feverish and suffered from the night sweats habitually associated with TB infection. She had visited her local clinic three times, only to be told again and again that she most certainly did not have TB.

When, in desperation, she finally presented herself at Tygerberg Hospital she was 20 kilograms underweight and very distressed. She fully expected, yet again, to be told she did not have TB.

Prof Reuter noticed immediately, however, that she had the classic symptoms of TB pericarditis. Her shortness of breath, swollen ankles and protruding neck veins were the outward sign; the muffled sound of her heart through his stethoscope the inner sign. Reuter was pretty certain that the bacterium which causes TB, Mycobacterium tuberculosis, had lodged itself in the membranous sac (pericardium) surrounding BB's heart.

An ultrasound scan of her heart confirmed his suspicions: the TB bacterium had caused a huge amount of inflammatory fluid to build up within the pericardium. While it is normal to have about two millimetres of fluid between the heart and the pericardium, BB had a massive four centimetres of fluid there.

This liquid overload causes pressure on the heart, which limits its ability to work: blood cannot return to the heart when increased pressure inside the cardiac chambers is pushing it back out again. This process severly inhibits the circulation of blood - and fresh oxygen - through the body.

It is this process which caused BB's shortness of breath, lethargy and the swelling in her liver, abdomen, neck veins and ankles. Her level of discomfort was so intense that she had not slept for days.

BB immediately consented to treatment. She was given a local anaesthetic and Prof Reuter inserted a sheathed needle into her pericardium. He then pulled the needle out; leaving the sheath, through which he fed a catheter. The unwanted fluid - all two litres of it - was then drained out of the pericardial space.

'The relief the treatment brings in its release of pressure and pain is so great that sleep-deprived patients often fall asleep during the process,' says Prof Reuter. But BB summoned the energy to sit up, put her arms around Prof Reuter's neck and give him a hug of thanks.

BB recovered from her ordeal with TB pericarditis and returned to her home in the Eastern Cape, where Prof Reuter is now reaching out to help the AIDS-ravaged rural communities of the region.

This work falls under the banner of the Ukwanda Centre for Rural Health.

'Ukwanda' is Xhosa for 'reaching out and supporting growth'. The philosophy behind Ukwanda, which was initiated at the end of 2002 by the Stellenbosch University's Faculty of Health, is to expand the faculty's services and activities into rural communities.

Students from all the health sciences in the faculty are taught to manage health issues in rural settings: they experience rural living conditions and are encouraged to reinforce their compassion for the sick and the poor.

'So much in health has to do with the environment, poverty and education,' Prof Reuter explains.

He started to support an HIV project at Lusikisiki in the Eastern Cape in January this year. 'We are supporting the community as consultants with expertise in HIV medicine as well as in rural health.

'The health situation in the Eastern Cape is heart-breaking,' Prof Reuter says. 'There are far more AIDS-afflicted individuals in the Eastern Cape than in the Western Cape. National Government is not doing enough.'

Prof Reuter's academic and clinical studies have paved the way for him to help poorer communities in very significant ways.