Dr Juli Switala from Pretoria has treated children in Nigeria, helped fatally ill patients during the 2014 Ebola outbreak in Sierra Leone, and has delivered babies at Afghanistan's Khost Maternity Hospital against a backdrop of upheaval and violence. These were some of her duties as an infectious diseases paediatrician for humanitarian organisation Médecins Sans Frontières (MSF).
Switala's career may have spanned the globe, but nowhere cuts close to her heart quite like Brooklyn Chest Hospital - the tuberculosis (TB) referral hospital on Cape Town's north-western fringes. Over four years at Brooklyn Chest, Switala treated tiny patients for multi-drug resistant (MDR) TB, extreme drug resistant (XDR) TB, some with TB meningitis, and some with HIV co-infection. Their treatment lasted anything from three months to three years; some young patients were orphaned, others had parents not in a condition to visit. (TB meningitis is TB that has infected the tissues covering the brain and spinal cord.)
'This is where I live'
"When you work at MSF, you go to places that are poor and desperate," says Switala. "But in a way, I still find Brooklyn [Chest Hospital] the saddest place I've ever been. Because when you go with MSF, you leave and go home. But here in Cape Town, this is where I live, this is my home, and the situation is not going anywhere."
She explains why TB in children is particularly difficult: "Because of their immature immune systems, the bacteria just manifests slightly differently. And the younger the child, the bigger the likelihood of TB spreading beyond the lungs - worst case scenario: to the brain. This means that they rarely have a 'classical' TB picture and usually present with varied, vague complaints that can be confused with a myriad of common childhood maladies from teething to gastro to 'crèche related cough' and sadly, it is often only when they present with extreme, severe manifestations that the true diagnosis is apparent."
The double blow, she says, is that many reliable diagnostic procedures for adults are nowhere near as accurate in children. "X-rays look different, sputum is difficult to cough up. It's understandable why healthcare workers who are perfectly competent diagnosing and treating adults are nervous of making the call on children and why we are missing more than 50% of children with TB, and that often children are only diagnosed once they have the most serious and often tragic manifestation: TB meningitis."
During the interview, Switala speaks fast between sips of chai tea at a café in Tamboerskloof, the Cape Town suburb where she lives. She adds that when TB is caught early enough, children have a good chance of survival and good health outcomes. "They are tigers when it comes to coping with the medications," she says. "They have fewer side effects than adults, and now that we have kiddy friendly formulations, it's easier to dose and administer medications at home. But even the best medication doesn't help if it's lying on a pharmacy shelf - and it won't be prescribed until someone feels confident they know what they are treating. So I see my job as assisting in case finding, supporting clinicians and getting those pills into mouths."
Since July last year, Switala has been a senior technical specialist in paediatric TB at healthcare organisation The Aurum Institute, based in Johannesburg.
Here amongst other projects related to childhood HIV and TB, she is helping with a trial to test [TB drug] rifapentine's safety when given with ARVs to children. "The highlight of my role [at Aurum] though is being partially seconded to the National TB Programme. This allows access to look at where great policy is not quite translating into reality, where our kids are being missed, where there is low' hanging fruit, opportunities for growth and in reality, where there are very willing healthcare workers who need assistance in gaining confidence to recognise, diagnose and manage TB in children."
'Just one more'
One of two siblings, Switala matriculated at Pretoria High School for Girls. Growing up, she wanted to become either a doctor or an advertising executive. A news clip on television swayed her.
"I think it might have been Burundi, there were scenes of people fleeing into the jungle because they were unsafe. An aid truck was being loaded with people. And this truck was so full, and then there was this old man. And he was like: 'please, just one more. Just one more!' And I was like, I want to help that dude! And of course, I do nothing like that now. But after that feeling the decision became easy for me - definitely medicine and not advertising."
Switala attended medical school at the University of the Witwatersrand, specialising in paediatrics and later paediatric infectious diseases at the University of Cape Town.
She glows with passion, her references to herself are often humble. She says she considers herself lucky - "I've never had TB, I'm so lucky I don't have a sick child. I'm so lucky I don't live in a country where there's a civil war..."
At 42 years old, she says a stand-out life lesson for her has been the importance of having empathy. "I really believe that everyone is just trying the best they can. I mean, people get so angry with big pharma, but even big pharma...I think the world would be better if we just gave each other some slack."
Switala's recollections are punctuated with anecdotes, detailing the humanity of patients.
"A Cape Town mom once said to me: 'Doctor, I'm sorry I was late for my appointment, but they were shooting in my area'. She was saying how her front gate looks like a cheese grater, because there's so many bullet holes in it." Another mother and her child walked 20 kilometres from Mitchell's Plain to the Red Cross War Memorial Children's Hospital (where Switala treated patients too) as the mother did not have money for transport."
"You can treat the TB, but you can't take away the real problems," says Switala. "The social problems, the poverty; the fact that a mother is on tik."
She sees lighter moments, too.
"It's the framing," she says. "There are thousands of disasters every day. But you get these miracles. Like at Brooklyn Chest, these kids who you really thought were not going to walk again. And then you just watch them turn the corner, they just recover way beyond. I mean, kids you do a lumbar puncture on [a needle inserted into the spinal canal] a really painful experience, but as soon as they wake up, they sit up to give you a high five."
A reunion
She recalls a romantic reunion sparked by a sick boy's treatment at Brooklyn Chest Hospital.
"Ironically, a kid getting sick from TB might actually be the best thing to happen to a family. Because that's what makes parents say, 'listen, we're kicking the drugs.' Or the mother says, 'I'm leaving this abusive man.'
"One of my favorite things, we had this nine-year-old boy admitted who just couldn't drink pills. He wasn't being naughty, he just couldn't. He used to take from nine to 12 o'clock to drink his pills, eleven tablets a day. And the nurses would break them into halves and the other kids would be his little cheerleading squad, chanting: 'come on just one more, almost!'
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"And his parents, they split up long ago. But they were both really dedicated to his care. And I remember we let him go home for a weekend and he didn't drink his pills and they brought him straight back. Anyway, through this process of working together to make sure he gets his treatment, they ended up getting remarried."
Difficult and special moments
On heavy days and during MSF missions, Switala says she lifts her spirits by going for runs.
"On the really tough days, the days where you just want to cry because there's a kid who died who wouldn't have died in any other country. On those days people knew, okay Juli's going to go for a run, leave her alone. She'll be better when she comes back."
In Afghanistan, she used a treadmill. "I was training for the comrades [marathon] at the time. After that, I never wanted to see a treadmill again," she says, laughing.
Special moments at Khost Maternity Hospital are still etched in her mind.
"Those are the nicest people I have ever met," she says. "All of the staff, everyone allowed in the hospital were female. Being just women in this area, it was so much fun. I remember one night, I went into the hospital sitting on a bench waiting to do a resus [resuscitation] or a Caesarean, something like that...It was like 3am and I'd just gotten there and I didn't feel well at all; I felt terrible. And this old lady came up and sat next to me on the bench. She must have been over 90; and she just took my hand, patted it, and gave me an orange."
