the glory and the horror

After a bit of an internet hiatus, we’ve both made it back on-line and made it back to the US. It did take nearly 48 hours, though, from the time we left the Madikwe Safari Lodge, caught a flight in Gabarone to Johannesburg, then back to DC via Dakar, Senegal. We were nearly 2 hours late into DC, so we missed our connection to Houston, so we caught a midday flight to Denver, then an early afternoon flight to Houston, which brought us into Houston about 10 hours later than scheduled.

Of course, our luggage is not here, but that’s ok, because we’re back safely, and we just wanted to be done with traveling.

We’ll have more about our last few days in Swaziland, and the BIPAI network meeting we had the chance to see a few days of in Gabarone.

From your local Swazi yogurt: Have a ding-dong day!

Above is a negative rapid HIV test. This test result means that there are NO circulating antibodies to HIV in the body. It is not a perfect test, because it is possible to have been infected with HIV in recent months and not have the antibodies in the blood to be detected yet. That’s usually more of a problem with adults. For children, once they have cleared mom’s antibodies (usually within 12-18 months after birth), a negative rapid test means there is no HIV in their blood. That is a wonderful and very important thing, because according to some studies, >40% of women coming for antenatal care are HIV positive, and without treatment of some sort, a good 25-30% of babies born to HIV-positive women will acquire HIV from mom. That means ~10% of all children in Swaziland would be born with HIV if the mothers got no treatment. That means that at 18 months, a little strip that looks like that is an amazing relief, because that means it’s one less thing to worry about for that Swazi child. There may still be other challenges to face, such as TB and malnutrition, but they will be more prepared to face those things with an intact immune system.

Above is a positive rapid HIV test. This test result means that there are circulating antibodies to HIV in the body. This means that a child may have HIV in her body, and for adults, it means that they definitely do. For those who see this result, it means that whether they like it or not, their world has been turned upside-down. In Africa, a diagnosis of HIV is still surrounded by stigma. Tie that in with certain cultural gender roles and expectations, and all of a sudden, it’s not so easy to get tested, much less get ARVs (anti-retroviral medications).

The ARVs are readily available. I am unclear on the exact funding sources, but it is my understanding that anyone can get ARVs for free in this country from any number of locations, ranging from in the city (like the Baylor COE) to outlying rural clinics (where we do our outreach clinics). Visits to Baylor COE are free of charge. Even so, there are wives whose husbands refuse to let them be tested, and if they are tested, refuse to let them start ARVs when needed, and when started, prevent them from coming back for follow-up and refills.

There are many people who fully acknowledge that there is an HIV problem, and that Swazis are dying in unprecedented numbers – and still refuse to get themselves tested.

This past Saturday, we went to visit the Swazi cultural village, a semi-working traditional Swazi homestead. It’s a bit more of a tourist trap now, but apparently a real family still lives there.

There was a nice presentation of traditional Swazi dance that is supposed to show off the strength and agility of the men. Essentially, they’re kicking their foreheads. It was very impressive.

Just outside of the Swazi cultural village, there was a family of vervet monkeys playing around. They were very cute and posed nicely for us.

Last Friday, we also went with an NGO known as Children’s Cup towards the Mozambique border, and here is us with our translator, Gugu. She’s a law student who volunteered during her reading period to teach in this one area of Swaziland, and she was also volunteering as an interpreter for us when we had clinic at this one church north of Simunye. It was there that we diagnosed the 70-something year old grandmother with HIV (and likely AIDS based on her clinical presentation).

Oh yeah. And if you’ve read this far down, it’s my 29th birthday today.

Today, I coded a 6 month old with one of the PAC docs. Today was the child’s first visit to the Baylor clinic. I can’t recall ever coding a child before. I did not imagine that I would be doing it in Swaziland.

We were initially informed of the kid arriving, and just looking sick. At the Baylor clinic, we have a mini-ER that we triage sick-looking people to for acute stabilization. As with many children who come in for their first appointment, we know little to nothing about what is going on. On first glance, the child didn’t appear to be malnourished, but didn’t look ok. When we walked into the room, he seemed to be breathing pretty hard, but slowly. I didn’t recognize it at first, since I’m not used to seeing children, but looking back, it seems clear now that the child was in agonal breathing. At first, I grabbed the oximeter while the PAC doc and a nurse started examining the child. Not sure where to put the adult-sized oximeter on the child, I left it on the exam table as the nurse asked for my assistance with the oxygen tank.

I was fighting the O2 tank when I turned back around and the PAC doc told me that the mask wasn’t needed anymore, and that we would need to bag-mask the child.

All of this was happening with the mother in the room. I didn’t get much a chance to look around, but I could see her out of the corner of my eye, sitting in a chair along the wall, clutching a blanket and watching us intently.

We started chest compressions and continued to try to bag the child. We still didn’t have IV access yet, but another PAC doc was trying to find any vein, anything, for access. We don’t have the ability to intubate here, as there is only one ventilator in the country (rumored to be reserved for the royal family), so we pressed on.

After a short time of bag-mask ventilation, the child began to vomit whitish material, presumably formula and/or breast milk, and so we suctioned the child as best as we could. There was no gag reflex.

We continued for a few more minutes, but it quickly became clear that there was little more that we could do. As soon as the child’s mother saw us taking the ambu-bag off and stopping chest compressions, she knew. Immediately, her wails filled the room and her face was wracked with pain.

Her child died, and we weren’t able to stop it.

This wasn’t the first child to die in the clinic, and it won’t be the last.

I get a little annoyed with just numbers, sometimes, because I feel as if we get all worked up over sheer numbers of patients, although in reality, that is part of the problem, and we do feel like we’ve done something good if we’ve been efficient and seen many patients in any given day. However, there are times that I wish we had the luxury of being able to sit with patients more to talk with them, understand where they are coming from, especially in terms of the cultural and social milieu in which they are operating.

This is especially true in a cross-cultural setting with the language barrier, and radically different living situations. This trip has reinforced to me a few of the things I had known before, but are so clear to me now. Any sort of long-term effort MUST be preceded by significant language and culture education for a least a passable understanding of how life works in the other culture. And it must not be neglected once in the host culture – it must be continued, expanded, and deepened so that the more subtle nuances are integrated into the ministry/work that one is doing.

As an example here, having done clinic in Mbabane for a bit, and asking folks about what water source they use, many people have access to clean water. Water that comes out of the tap in Swaziland is usually safe, unless the tap is getting water from an untreated groundwater well (few, but possible). Then there are those who live in relatively rural conditions who still get their water from the river, and do not boil it before drinking it.

On the surface to many westerners, myself included, there doesn’t appear to be THAT much of a difference in the living conditions of the patients I’ve been seeing in clinic and in Mbabane Government Hospital (the other MGH) compared to those out in more rural parts of the country. Many homes are constructed from concrete, brick, or CMUs, have glass windows, corrugated tin roofs, and so on, and the ones around town look very similar to the ones you can see further out of town. If you didn’t know that a lot of those homes didn’t have clean running water, you could mistakenly assume that since the domiciles look similar from the outside, the inside was probably pretty similar as well. And that would be wrong, and we would be missing a major source of problems.

We went with a faith-based NGO Friday, Children’s Cup, to one of their outlying clinics in the northern lowveld of Swaziland, north of Simunye, deep in the heart of sugar cane country. It was there that I wished I had more language and cultural knowledge. Almost every adult I spoke to said that they drank water from the river without boiling it. Multiple people were HIV positive, and had their last CD4 count checked in 2007 sometime, some as low as 201. This, all in a country where they can get free CD4 testing and free antiretroviral medications courtesy of the government, NGOs, and the pharmaceutical companies. I wanted to sit down with each of them and try to do all the counseling that I know is done at the Baylor Clinic when people are diagnosed, started on ARVs, etc. But I couldn’t. I lacked the the time and language skills, even though I had a very capable interpreter in Gugu, a law student. It is times like those that I have to trust God and the people He has placed on the ground here in Swaziland to do the followup.

One 40-something HIV+ gentleman had been hospitalized 9 months ago for 20 days with some sort of paralyzing illness that was slowly getting better with therapy, but he didn’t know what it was. He had no recent CD4 count. He came to me asking for pain medicines and to make him stronger. There is a helplessness that sweeps over you in certain situations, such as this, where you wish you could help him more, but you can’t. We were there at the church putting on a one day clinic. What he needed in terms of medical care, we couldn’t provide. He needed a system in place to help him access the resources that were available to him. I couldn’t explain what resources were available to him because I have a very minimal knowledge the system that does exist in Swaziland.

A 73-year-old grandmother came to us wanting medication for her chronic diarrhea, and was clearly wasted, weighing 30-some kilograms (1 kilogram is 2.2 pounds). Initially, she was seen by one of the US nurses that was with Children’s Cup, and immediately was sent for HIV testing. She may be the oldest person that I have ever had to tell that she was newly diagnosed to be HIV+. She was stunned, and couldn’t believe it. She kept on asking us how it was possible, as her husband had passed away some years ago. She kept on insisting that she hadn’t had sexual intercourse in years, and that she had only slept with her husband. We had little to tell here, in terms of the past. We had no answers for her questions. We could only encourage her to look forward, to get further testing, and see where her immune system stood. We knew that there was little we could do medically for her besides some metronidazole and comfort. We got to pray with her, and make sure that she knew that she could find support at the church. We made a concerted effort to reassure her and tell her again and again that it wasn’t going to do much good for her to worry about what happened in the past now, but that it was important for her to be thoroughly checked out to make sure she remained as strong as possible.

Many of these more rural patients have little framework for understanding the many things we are trying to teach them about basic sanitation. Few are literate, and even fewer have a working understanding of germ theory. They feel if it’s been good enough for their ancestors (and there is much reverence for the ancestors here), then it’s good enough for them. It often takes many sessions of counseling and teaching for some to grasp the concept of loss of their immunity due to HIV, and the many things that come with that.

Language and cultural insight are indispensable. We can only do so much in the individual patient encounter. To truly change things, to really make a difference, we must understand how things work in a certain setting, so that we can analyze it and work for real change within a culture. That applies to medicine, to missions, to teaching, to governing.

All I’ve got is “Sawubona” and “Unjani?” and “Siyabonga.” Three weeks seems much too short. I am so glad for those who are here for the long haul.

We had the pleasure of going to church Sunday at Mbabane Chapel, a non-denominational protestant church led by a Scottish Baptist pastor. We also ran into our old friends the McCollums, who have actually been away from the Baylor clinic on vacation. We also met Amy’s parents, who are visiting them right now. We also saw a few other PAC docs (Richard and Julia) there, as well as meeting a number of Swazis and expats, all attending the same church.

It swas an interesting mix of people, as most expatriate-type churches are, IMHO. There seemed to be a significant local Swazi contingent, some visitors from various parts of the world, and many expatriates from South Africa, Western Europe, the US, Canada, and even Asia. It seemed to draw a fairly wide diversity of people, and from the sermon and liturgy, it seemed to be a fairly typical non-denominational evangelical church. I enjoyed the sermon on unselfishness, as it seemed to do a nice job of bringing everything back around to Christ as the ultimate example of unselfishness in his death on the cross.

As I mentioned in a prior post, Swaziland is reportedly 80% Christian, although it’s arguable how many of the churches actually line up with orthodoxy given the large number of Zionists. From what I’ve heard in talking with expats and Swazis here, there is a broad range of theologies encompassed among the Zionists from minimal adoption and integration of traditional beliefs into Christianity, to a very syncretistic mish-mash of beliefs. According to what I heard, the colors they wear on Sunday to church indicate which sect of Zionism they belong to. Unfortunately, Wikipedia is not much help on that point.

I haven’t read enough to say much of anything about the indigenous churches, but something that did occur to me is that among the expats, there was probably a much broader spectrum of “Christians” at Mbabane than you would probably find back in the US. I think with the availability of different denominations/churches to serve various groups with their varying doctrines, it’s easier to make smaller and smaller divisions, such that in the great big pie of churches, there are many slices. My feel here is that Mbabane Chapel just has a wider swath of Christianity than possibly any church I’ve been to (of course, that’s strictly a gut impression based on one Sunday).

I’m not sure if I really think that is a good or bad thing, if that is the case, although I supposed it all depends on exactly how much ground is covered in that “wide swath.” Part of me is happy that it’s not just some homogeneous cook-cutter congregation of copies (wheeee! Alliteration!). I guess a lot just depends on the church leadership, as it is with lots of churches and denominations in the US.

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From the perspective of the medical side of things, I continue to be amazed by just how many people keep on coming through. I was at an outlying location on Tuesday and Richard (one of the PAC doctors who has been here since last August) and we saw 48 patients, nearly all via a nurse interpreting for us. It took us nearly 2 hours to drive to the site, and we saw patients on-stop for about 6 hours. Among those included some great stories of CD4 counts climbing back up, kids gaining weight, making developmental milestones, and just looking a lot better. There have also been at least two mothers we have seen in clinic so far who recently lost children to AIDS-related illnesses. We saw over 120 family units in the main Baylor clinic last Tuesday. We saw over 100 today.

Of course, it’s all relative to how Swazi culture works, but basically, most things shut down around 5 or 6 pm, except for restaurants. It seems that the day starts kinda early, but then everything becomes REALLY quiet and slows down a lot after dark. We were even told that the general thought is that if you’re out walking around after dark, you’re up to no good. So putting that all together means that clinic is pretty much hopping by 8 am, and we just see patients all day long. The PAC docs generally eat along the way.

I’ll add more later this week, with a few pictures and more detailed stories.

Kathleen and I had our first full day off, so we spent the afternoon together riding around the Mlilwane Wildlife Sanctuary in Swaziland’s Ezulwini Valley. We weren’t sure what to do exactly, so we hired a guide and rode horseback for several hours, exploring the beautiful country.

We saw a lot of elegant and beautiful animals, including zebra, warthogs, blesbok, nyala, kudu, and wildebeests. I think I got pictures of most of them, although I thought I’d try the kit lens first, since they didn’t seem so scared of humans, cars, or other signs of civilization. There were even a couple crocodiles. We had to stay away from this water, because according to our guide, they can jump 4-6 meters out of the water to say hi.

We also managed to see a few families of animals. We learned that when zebras walk, mom leads the way, and then the kiddos follow in birth order, eldest to youngest, and then dad brings up the rear. I told Kathleen we should be a zebra family and tell our kids to line up that way when we go traveling.

Not bad for the kit lens, eh? I really should have taken the telephoto, but we could only take the camera, and not my bag, on the actual horse, so that limited what I could have on me. If we go back to Mlilwane, we were thinking we might rent bikes instead next time, so that we could carry food, water, and lenses with us.

When we got back to the main camp area, I did switch out to the 70-300 f/4-5.6, and as I mentioned above, the animals weren’t scared of much. So a family of warthogs just starts hanging out in the main camp area. Of course, I couldn’t help but hear Poomba singing, “When I was a young warthooooooog!”

They actually seemed like rather clean and nice animals, and they just sat there, nosing the ground and hanging out. The lens could get up close and personal, as you can see. I was at least 25 feet away. The lighting wasn’t the best, and I’m still learning how to use this camera to get the best shots.

According to Kathleen, the real gas-passer on this trip was my horse. Every time we picked up the pace, she said she could hear my horse let loose. That’s what she gets, I guess, for being last in line.

Unfortunately, Kathleen lost a hoodie on the ride, which we doubt we’ll ever recover, but we left notice at the front desk just in case. If we get that back, that’ll be another amazing thing about this country. People are already very nice and extremely polite, and if this hoodie somehow comes back to us, well, that would just be icing on the cake.

Also, just so you guys can see what else I’ve been doing, here is the blog of a Dutch Reformed missionary to Swaziland to helped for the Swaziland Reformed Church. It was during my research for my last post that quite randomly (thank you, Google!) stumbled across his blog and the things that he and other Christians here in Swaziland are doing. I was particularly impressed by the AIDS home-based care ministry. With my interests in outpatient palliative and hospice care, seeing this happening always warms my heart. In resource-poor places, while we may not be able to aggressively treat and cure as much as we can in other places, we can still manage symptoms and pain and address other psychosocial, spiritual and emotional needs of patients as they are still going through the process of being sick, and then dying. That is something that the Church needs to step up in, both in developed and less developed situations.

I didn’t mean to punch you. I was just trying to warm my hands.

- Said by the wife after punching me in the side while trying to stick her hands in my armpits to warm them. It’s not that all that cold over here.

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A few facts about Swaziland:

• Swaziland was a British protectorate for a while, and part of the push for their independence was in response to increasing racism in South Africa in the mid-20th century.
• Just over a million people live in Swaziland.
• At least a third of all adults aged 15-49 have HIV. A recent study found 56% of women aged 25-29 are HIV positive. That makes it the highest prevalence rate of HIV in the world.
• The dominant religion is Zionism, a syncretistic blend of Christianity and traditional folk religions. Operation World reports the population as over 80% Christian.
• There is one mechanical ventilator in the entire country, or so we were told today by one of the BIPAI PAC docs.

All of our luggage got here today! Yay! That is a full 48 hours after arriving at the Baylor clinic site (the COE – Center of Excellence). Only one bottle of sunscreen decided to free itself from the constraints of its container, and even then, it was content to only ooze in the general vicinity, and wasn’t too eager to explore all the crevices of our bag.

Looking over the rolling green hills of Swaziland from the clinic windows, I have to say that I have been amazed by the experience so far.

After a late arrival last night, a couple of the other expat PAC (Pediatric AIDS Corps) docs – Fiona and Michelle – took us out for some really good food at a local eatery called Nando’s. The grilled chicken and potato wedges (peri-peri wedges) were just right after a long day and a half of so-so airport food and less than so-so airplane food. I have also rekindled my love with the more unique fruit Fanta flavors – yesterday, I had a pineapple Fanta. I don’t know if I’ve ever had pineapple before.

The first part of the first day today was spent meeting lots of important people around the clinic that I can’t remember even now, less than 6 hours after meeting them. However, I’m sure that I will learn their names, because they’re the lab folks, pharmacy folks, social workers, nurses, and other very helpful and indispensable folk around the clinic.

It’s been a bit weird to relearn to see children, although I think it’s not as much of an adjustment as I thought. I do have to remember to ask a few more questions, especially about their feeding habits, and how caretakers are making formula, and things like that. Some of the stuff is the same old basic stuff – URIs, gastro, and the like. The added twist is that some of these folks are on 3 antiretrovirals, and can have some low CD4 counts.

We also went grocery shopping and stocked up pretty well, we thought. We spent just over USD$50 and we’re probably good for most things for the next few weeks. Might need some more fruit and meat, but that we can get along the way. Plus, another resident is coming next week to join us for a bit, so we’ll probably make another run for them to pick up stuff as well.

As mentioned in an email, our checked bags are still not with us yet, but will hopefully be with us by tomorrow afternoon. At least one bag made it to the international airport this afternoon, but we didn’t have time to find a ride down there and pick it up. Tomorrow, though, hopefully, we can have someone help us out with that, and hopefully, all 3 of the bags will have arrived by then.

For future BIPAI’ers to Swaziland, remember to bring SEVERAL changes of clothing.