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The tuberculosis ward at the hospital Point G in Bamako, Mali, is on top of a hill at the farthest corner of the hospital grounds. It's situated next to the dump, where the smoke of incinerating hospital waste and the bacilli from the TB ward head off together with the prevailing winds.

Last January I joined a pulmonologist from Cuba, a Malian physician, and a group of Malian medical students on rounds at the TB ward. I run a TB- and HIV-vaccine research lab at Brown and was visiting Point G to explore the possibility of collaborating with Malian TB and HIV specialists. Our team went up to the second floor, where the worst cases are kept, three to a room; outside, in the hall, family members camp on pallets. There I saw Pott's disease (TB of the spine, rarely seen in the United States); I saw miliary TB, in which the disease spreads rampantly throughout the body; and I saw a man so wasted from TB that his limbs were no larger than the iron legs of his bed, his knees like swollen knots of bone.

I saw a ten-year-old boy - the same age as my daughter - with Mycobacterium bovis, a form of TB acquired from unpasteurized milk. The infection had destroyed his hip joint. He was a herder of the Dogon tribe, whose herders all drink their animals' milk raw, unpasteurized. The boy's mother held him up so I could examine him. He could not stand because his hip was fused - it will always be like that, for there are no hip replacements in Bamako. She said, when I asked, that he was better. What is better? I wondered to myself.

I asked my fellow physicians how many of the TB patients had HIV infection. No one knew: 20, 30 percent. The test is seldom done because the patients must pay for it, and they have neither the money nor the desire to know. Why get tested for HIV if there is no available treatment?

At the AIDS Ward, located in the oldest building on the hospital grounds, I visited patients with Dr. Mintah, its director. I saw a woman bent double at the waist, like a hairpin, paralyzed in that position on her bed. She knew she was dying. She didn't look at us; she was too busy holding her pain. I saw a man just barely breathing, a bag of bones on a bed, and heard his story from his brother, a doctor, who was caring for him because there are so few nurses in the ward. The doctor said his brother was told "a long time ago" that he had AIDS but didn't want to believe it. I asked how long ago the man had learned he had AIDS, and the brother said two months. That brought me up short. Two months is a long time if you don't know that with the right daily-medication cocktail, HIV patients can live as long as their age-matched peers. Dr. Mintah hears about the new drugs, but they are simply not accessible to his patients. He showed me another patient, a young girl who'd been abandoned by her second husband (her first husband and a child had died of "unknown" causes, probably AIDS). Dr. Mintah believed the girl could live, so he was bringing her AIDS medications for which he had paid himself.

That same week in January I attended an evening reception at the U.S. ambassador's house. There was ample food, drink, and laughter, on a lawn as thick and green as a carpet - a cushion of comfort between ourselves, the ambassador's invited guests, and the reality of Point G. Standing there, I felt as if I had descended to the last circle of hell and returned to drink a Coca-Cola with the visiting president of the University of Michigan, who was there to talk about food aid and agricultural support. There was a problem with his plan, I thought: what will happen to the farms when the farmers have died from AIDS?

There is more to Mali, and to Africa, than AIDS and TB. Despite AIDS, despite the lack of access to curative drugs and preventive vaccines, life in Mali is vibrant. I was happy to be there last January. But my visit to Bamako was sobering, a stark reminder of how important it is for researchers - my small group at Brown and those elsewhere - to develop vaccines as quickly as we can. Mali is one small corner of a vast continent full of AIDS and TB, and the enormity of the problem can seem overwhelming. But if we don't begin somewhere, we will never begin.



Assistant Professor of Community Health Annie De Groot is an infectious-disease specialist who works on HIV and TB vaccines.




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