A day in the life of Dr. Rolando A. Cedillos

IAS Member and Head of Infectious Diseases, Hospital Nacional Rosales, El Salvador

A typical day starts early in the morning at the hospital, doing rounds and teaching medical students, interns and residents at the only infectious diseases hospital facility for adults and adolescents in my small country.

I have been Head of Infectious Diseases at Hospital Nacional Rosales, the largest public hospital and the only tertiary care facility for medical and surgical conditions in El Salvador, since 1998. Twelve years ago, with the help of a multidisciplinary, voluntary team of co-workers, I founded the first comprehensive care programme for HIV/AIDS patients in El Salvador.

On any given day almost all of our patients have full blown AIDS. Although antiretroviral therapy (ART) has been provided free of charge at my hospital by the Ministry of Health in El Salvador since 2000, we still see a lot of patients coming in with advanced disease, and so dealing with opportunistic infections like histoplasmosis, tuberculosis, toxoplasmosis and cryptococcosis is a daily effort.

Also accompanying me can be interns and general practitioners who are providing antiretroviral therapy in the interior of the country, and who are doing a week long rotation with us. Implementing this practice in 2003 has enabled the decentralization of treatment and care for HIV/AIDS in the public system. This has meant that, in geographical terms at least, no one with HIV in El Salvador is now more than 1 hour away from antiretroviral therapy.

After rounds I go to the outpatient clinic, the busiest HIV/AIDS clinic in El Salvador where nearly a thousand patients are enrolled. There, we take referrals from all over the country and even from neighbouring ones like Honduras and Guatemala. Our hospital is the end of the line for El Salvador`s health system so we really cannot turn patients away. This guarantees that along with the routine check ups, we will also receive challenging undiagnosed referrals. The outpatient clinic is also a microcosm of my country’s epidemic with a mostly heterosexual population that includes teenagers and senior citizens but also an important number of gay, transgender persons and sex workers.

During the morning I also take calls about the management of cases from physicians who work in clinics that have been set up all over the country replicating our model. Before lunch I try to make it to the emergency room where a large part of patients are still first diagnosed when they come in referred from primary care clinics, secondary level of care hospitals or directly from the street. AIDS is still an unfamiliar disease for a lot of doctors in this part of the world.

In the afternoon, along with the resident we try to check up on patients in the rest of the hospital, discuss difficult cases and try to make time for developing team projects. These days we are trying to set up the first comprehensive programme of care for men who have sex with men (MSM). In my country, HIV prevalence rates in this group have been as high as 17%, and MSM are clearly an over burdened group that needs special focus.

It has been said that in Latin America there are no homosexual men, only bisexual men because of the need to conceal their true sexual orientation in a setting of widespread machismo and discrimination. At our large hospital, gay, bisexual and transgender persons are a familiar sight to health workers and they clearly feel protected in numbers, but we still have to make care and prevention, particularly in surgical services like urology and proctology, more welcoming and atuned to their needs.

Unfortunately, as elsewhere, stigma and discrimination have been a big part of general attitudes toward patients but also of the way resources are allocated. All of our work is done within the constraints of the hospital`s budget and this year we suffered the elimination of a physician’s position due to “lack of funds”. To have this happen in a context of rising numbers of patients and even an increase in the hospital’s budget is very telling of the prejudice the authorities have toward patients and issues of HIV/AIDS care. A part of my day, then, is also taken by the constant fight against stigma and discrimination both within the boundaries of the hospital and outside.

In the evening at home. sometimes with a full heart, and sometimes with an empty one from the days`s fight, I try to catch up with my wife and two small children and recharge for the next day.