N. R., Kilema Hospital , January 12, 2008

It is the look in N.’s teenage eyes which alarms me, a resigned and detached gaze I have not seen before from him.

Today his eyes completely lack the brightness and animation I have come to look forward to at all our visits, to which he comes alone, the routine the same each time as he sits across from me and leans forward intently, planting his elbows firmly on the desk with hands folded.His intense brown eyes then lock on mine with a definite purpose and ask, “How am I going to get better?”

When visiting me at the HIV centre, N. has walked several kilometres and I wonder what those long kilometres are truly like for him in recent months as his health has steadily declined.His HIV has stubbornly progressed to Ukimwi (AIDS) since October, despite him starting and faithfully continuing all the medications I asked him to take, morning and evening.For several years N.’s face has had blistering fungal infections, accompanied by darkened and elevated patches of skin announcing the presence of Kaposi’s sarcoma, vascular lesions brought on by the progression of HIV infection.Until this past autumn, his family avoided bringing him to the centre for care, the shame of a child so clearly affected by HIV too much for them to deal with.

But as this intelligent and confident boy monthly sits before me, many questions are unavoidable.How does he view himself, victim or responsible for what has happened to him?What looks and murmurs from local children and adults accompany him on his walk to see me?What future has he imagined for himself as he sees that his body does not grow and develop like his schoolmates?

I will never know the answers to these questions.N. always beams a curling, sneaky smile as he answers questions about how he is doing and he confidently explains his plans for his studies or other activities at home, dismissing uncertainty or the possibility that he will not achieve what he has planned.I am struck by the contrast of how physically ravaged by HIV he appears to me and his robust attitude to the future and what he plans to achieve.Struck but not really surprised any longer, each day among the people of the Kilimanjaro region showing me new examples of resilience and determination.

But today is different.We now face each other on his bed, one of sixteen in the adult male medical ward.He looks misplaced, a child among men, but at the age of fifteen he has moved on from pediatric in the classification ofKilemaHospital.This is a particularly cruel classification to N..He looks as though he should be a playmate of my son Lachlan and indeed he sharesLachlan’s seven year old stature and weight.

He has new and severe chest pains which bring him to tears, worsening cough with bloody sputum and shortness of breath.His eyes have dimmed, his gaze directed beyond my perception.These are the same eyes into which I looked in November and December and spoke hopefully about HIV medications halting or reversing his Kaposi’s sarcoma, skin infections and recurrent pneumonia.But I have just looked at his chest Xray of yesterday and in addition to worsening pneumonia he has a new shadowing at the lung bases and probable spread of his Kaposi’s, a very poor prognosis in one so young and fragile.

I can do no more to help him in Kilema.

N. will require transfer tomorrow to Moshi, for an attempt at chemotherapy to halt the destruction of his lungs, lungs which are far too small in a body never given a chance to grow normally, from a virus he received through no fault of his own.A malicious cascade.I wish I could tell N. that I could reverse or undo all this.

N.’s gaze returns to me finally, as if he senses my discomfort and is trying to help me. “When will I be coming to see you in the clinic?” he asks.

“I hope I’ll see you there in two weeks,” I reply weakly, grasping for hope.

“I will be there,” and his grin curls, faintly and slowly but definitely there.

I wave at this small but brave boy among men as I leave the room, clinging to the image of that grin and the hope that those elbows with folded hands will, against all odds, soon be planted firmly on my desk once more.