Reports from Swaziland

We started our day with a served breakfast: hot dog meat, eggs and beans. It was a surprisingly American meal with toasted bread, peanut butter, jelly and cereal. We had not had a chance to meet Veki, the owner, for her to explain to us the specifics of our housing situation but the rent seems to include breakfast. At the shared dining table, we had a chance to chat with the various guests living in the same complex as us. (Z’s and my rooms make up a backyard cottage separate from the main house where the other guests had rented rooms.) The others come from different areas of Swaziland and one, even from Lesotho.  Their professions range too, from business to statistical analysis. All were encouraging us to enjoy the hospitality and culture of Swaziland, but when we asked which spots we should pay particular attention to, they could only direct us to tourist agencies, as if many areas of Swaziland are not opened to the public.

 Dr.Stephanie Marton, the PAC doctor coordinator, picked us up promptly at 7:30. She was a tall, thin woman with a clear voice and confident air as if she had traveled the world. We later found out that she had been to Japan, Cambodia, Nicaragua and now Swaziland, which gave her a great background to further pursue a fellowship in global pediatric health. As this is an area I am interested in, I am excited to have her as a mentor.

The Baylor Clinic, just down the street from us, is painted yellow, green and red to gave out a friendly but unassuming air. At first, I thought the clinic would stand out from its neighbors because it had looked very fancy on the BIPAI website, but I am glad it blends well with the surroundings, not squalid but not showy either. We were immediately given an introductory tour around the place. The clinic, like all other BIPAI clinics, was organized in a circular, two-story architecture so that you can never be lost if you follow the hallway. The first floor is for the exam and treatment rooms while the second, the executive and management offices. The clinic’s main purpose is to serve children with or is at risk for HIV and to treat HIV/AIDS incurred diseases such as TB. However, if family members are also infected, then they are also given medicine so that the family does not have to make two trips: one to the clinic for the kids, the other to government hospitals for the adults. It was a relief to know that all ARV and TB medications are free, made possible by the support from the government, PEPFAR and the UN, as Swaziland has the highest HIV rate in the world.  Each room was well equipped for its purpose and looked often even nicer than exam rooms in the US. The clinic also has its own CD4 counter, a hematology machine and electrolyte analysis technology. However, the best imaging device accessible to the doctors remains  the x-ray for diagnosis and many kids often die in the ER due respiratory problems untreatable because of the lack of ventilation capabilities. Along our tour, we were introduced to the team of Swazi volunteers, nurses, expert clients (women openly HIV+  who works to counsel families) and technical staff who support the clinic. Unfortunately, their names are too foreign for me to immediately remember. We will be working closely together with them on our future projects, so I look forward to knowing them better. A few American doctors and visiting scholars were also present, but most were in the US visiting their families after a recent conference. We meet a married couple, Dave and Amy, who has a family in Swaziland of two children and is currently in the process of adopting a Swazi baby.

During the tour, Stephanie introduced to us a few of her projects ideas. One was organizing the library and using the storybooks to start a daily activity time for kids in the waiting room to read and draw. It sounds like a great project; Z and I wanted to began this as soon as possible.  On a related note, I am also excited to find that there is also a teen club that we can become involved in. Another serious need the clinic would like our help on is to reorganize the x-ray files as some are often are misplaced when doctors need them to diagnose a patient. I don’t see a need for the bili-lights based on the tour because the clinic is solely concentrated on HIV treatment and has no impatient admittance or a nursery. However, the clinic routinely collaborates with rural clinics and government hospitals on outreach activities so I am hoping to introduce the device then. The two backpacks would also come to perfect use during the outreach days. 

We spent rest of the day in the adherence and screening rooms. In the former, we observed how the social worker counted the pills, inputted the leftover number on the computer and recorded the computer –calculated adherence percentage. Most pills did not take long to count because they were packaged in plastic bags that were transparent on one side, making visual counting easy. Dealing with liquids was much more troublesome and time-consuming. The worker must empty the liquid out on a small measuring cup. When the cup is filled past the labeled lines, she must use a syringe to suck the excess in order to determine the exact amount. I think we could introduce the dipstick method developed last summer to measure liquid adherence, but I seriously wonder if daily Swazi workers  are open to change. For one, the workers strictly followed what was taught to them, displaying very little flexibility and understanding that comes with experience. They have been using the computer for at least a year now, but they still use a roundabout, classroom-taught way of filling the data that shows they have no understanding of their experiences. When Z and I discreetly showed them diffent ways to cut corners, they remained set on their course. But perhaps, I am being too harsh; we are new to the clinic and younger than them.  The experience does show an interesting challenge in the future. 

The screening room is where exposed infants (newborns with undetermined HIV status but with a HIV-positive mother) and new patients are tested and admitted. For accurate results, the Dry Blood Spot is preferred. Drops of blood are collected on a paper, dried and then sent to the government hospital that then mail it to South Africa for HIV/PCR test to screen for the HIV viral DNA. The entire process can take at least six weeks whereas in the US, it takes about three days. The clinic also uses the rapid HIV dipstick test that determines the presence of HIV antibody. Unfortunately this is less reliable because the antibody can be passed from the HIV positive mother to the child during childbirth. Even though I did not understand a thing that was said between the nurse and the patient during screening meetings, I liked my time in there because I could play with the kids and exchange a few words with the mothers.

We did shadow Stephanie individually. During my time, there was an interesting case of TB in a kid who just finished the standard 6 months treatment and looked recovered but his x-ray showed a suspicious cloud in his lung, which alerted Stephanie to continue treatment for at least a few more months. What interested me, though, was that I saw the mother and the child when we came in that morning when the clinic was just opening, around seven. I saw her with Stephanie in the afternoon around two. She has been in the hospital for almost a day. A really LONG time. I am tempted to study the issue further to evaluate the efficiency of the clinic.

Another interesting aspect I noticed about the clinic is its demographics. Most patients who come in are pretty well dressed, much more so that I had expected. Some wore stylish blue skinny jeans, others, long styled skirts with beautiful scarves or stylishly-cut sweaters. Most of all I guess as Z noted, they have shoes. I wonder about the socioeconomical class the clinic serves. As the services are free, I thought I would see more of a variety or discrepancy in patients but I really did not. The reason might be because we were in the city where people are more relatively and evenly well off. However, every city has its poor, so I wonder if the uniformity is related to education that only the rich can afford.  From my one day of experience, I feel the reason leans toward the latter case. Throughout the day I had asked the moms about their kids concerning school attendance. Most (except one) were which says a lot because in Swaziland, there is no free education, only a current ongoing debate about free primary education. Or perhaps I was being lied to as I detect a strong pride in the culture. I meet a grandmother who brought only one of her five grandchildren to test for HIV only because she believed the daughter-in-law was lying that she was HIV negative (the grandmother earned her title to five grandchildren in one year!). She told us herself that when her eighteen-year old son informed her that he has gotten a girl pregnant, she could not believe it, that she asked him how did he know the child (or as it turned out to be twins) was his.

So many great things have happened to us already on our first day! A great schedule is slowly manifesting, thanks to the fantastic Swaziland hospitality. In one day, we have gotten invited to so many places. The financial coordinator at the clinic invited us to a cycling competition on June 6 and volunteered to show us around city and hikes on future weekends. The doctors at Baylor are also a social bunch. Stephanie introduced us to a nearby gym, a block away from Baylor, where we could take spin classes with her. Dave invited us to join him on the doctors’ morning run every  Wednesday and Friday of about six miles. Z, being the soccer athlete, really wants to participate but I am not sure I can do it but I am determined to try. The main thing that worries us is that the run starts at 5:30 but doctors’ start of the run is actually quite far from our house, about 4 or 6 kilometers. Hopefully when the remaining doctors return from the US, they could give us a ride on those mornings. Our tenant, Veki , whom we meet in the evening, was wonderful too. She has already invited us to her party on Saturday to meet with her other guests, including three Italian girls and two other Americans all near our age. I am very excited about all the future projects and activities that are shaping out. 

Finally. Finally I am at Mbabane, Swaziland. After spending a day here, my life in America and what I have done in the recent past—my trip here, my week of little sleep  (in order to finish my project)—seem far away and long ago. Swaziland is real; America, a dream. I think it is appropriate to start from the beginning, but I must warn whoever reading this that I am writing a blog for the first time.

I am on a ten-week internship in Africa. I will be spending 5 weeks in Mbabane, Swaziland to work in the BIPAI Center of Excellence and another 5 weeks at St.Gabriel’s Hospital in Malawi. My travel companion, Elizabeth or better known as Z, and I have brought with us three projects that we hope to introduce, implement, analyze and improve upon during our stay. One is what I have been working on in the past year: a neonatal jaundice phototherapy device, or for short, the bili-lights. The nickname fits because the device uses blue 470nm light from LEDs to breakdown the excess buildup of bilirubin in newborns’ blood. The bilirubin–a yellow component of hemoglobin decomposition–is the cause of the yellowing of skin in infants, a condition known as jaundice.  If this fairly common condition is left untreated, kids will develop hearing loss and mental disabilities. I am hoping that the two 60-dollar models (compared to the current devices averaging over a few thousands a piece) I brought to Swaziland will find a need and true use here. The other two projects are the Diagnostic Lab-in-a-Backpack and its spin-off, the Community Health Worker Screening Kit (CHW kit). Both use backpacks to organize and store medical equipments traveling doctors need on their outreach trips to easily assess an individual’s health. The former provides doctors with helpful diagnostic tools–such as urine dipstick strips, a microscope and centrifuge—that are backed up by a solar-charged battery system. The latter is a backpack to support community health workers in basic checkup and assessment of local primary health.

The bili-lights, compounded by the fact that we have no access to the internet at our guesthouse, are the reason why I am blogging this late. Last week, before I left on Saturday, I made about twenty bili-lights that will travel with a few summer interns and myself to be tested across the Atlantic Ocean from Haiti to Malawi. I have gotten at most four hours of sleep these past few days, including the plane ride here, so I can’t wait to catch up on some solid rest in Mbabane. Despite my current state of sleepiness and the ominous pouring Houston rain on the day we left, our trip so far has been blissfully smooth and fun. We enjoyed a wonderful 12-hour layover in London that gave us ample time to take an impromptu walk around the famous city. Armed with only a map, our group of eight interns to Africa (we were together until South Africa) rode the subway that took us from Heathrow to the heart of London. Westminster Abbey, Buckingham Palace and the Parliament stunned me with their intricate beauty and the heavy weight of history filled with blood, wars, and glory. However, it is the little things I noticed that fascinated me. There is a distinctive modern air of freedom in the city, seen immediately in its people, in their edgier, if not sometimes downright outrageous, fashion.  Within a few minutes of strolling down the street, we saw a lady biking in her bra—definitely confirmed by the lacy and intimate design. Yet, a deep sense of classic activity untainted by the droll of television or the smog of cars was infused to the city. Bikes were a common type of transportation but so were roller skates, as I witnessed for the first time. Lush green parks popped up randomly in between blocks with couples and families settling busily in the shade, reading newspapers or sharing food beside the type of classic picnic baskets I have only seen in movies. (Picnic baskets rather than coolers!)

What made the plane trip truly light on my heart was that our luggage arrived safely with us to each transfer point; i.e. we landed in Swaziland with all our bags. (Luggage is renowned to be lost during inter-African airline transfers.) My luggage bag did have a suspicious tear at the bottom when I collected it at South Africa airport, but none of my things were lost. In fact, I was hugely surprised that we did not have to pay overweight charges on the 61 pounds bili-lights-and-CHW-screening-kit suitcase on South African Airline (SAA) flight to Swaziland. (We did for Continental.) According to SAA website, they should have charged 50 dollars per kg over, which meant that we would have paid around $300. I guess the reason our luggage did not get lost was that we actually saw the workers load each checked-in bag onto the plane. I think Z and I both held our breath with each lift of a bag as we hoped it was ours. We luckily had the right draw because whereas our suitcases were loaded, we saw five other bags being left on the docking station. What a small plane it was!  My first time riding a propeller plane no less. Z and I actually sat next to the spinning propellers and shared a look of raised eyebrows. It turned out to be a noisy but smooth flight.

We landed in a small town near Mazini, the industrial center of Swaziland when the purple of twilight was given away to night. We were very glad an experienced taxi driver was sent to pick us up because we encountered a minor hiccup right away. The officials asked to search our black boxes that contained our projects before we checked out. Despite the note Z showed them declaring that the cases are free gifts to Baylor, the officials were reluctant to let us pass, relentlessly asking us for a complete list of the items in both cases. The taxi driver came to our rescue. After a few minutes of Siswati being exchanged, we came out with everything. On our 40 min car trip to Mbabane, we were presented with a beautiful, sparkling image of night view Swaziland. We were surrounded by towering mountains darker than the sky, illuminated only by the sparse twinkling of lighting from houses perched in darkness. I was surprised that there were still many people–many women in fact– walking on the side of the streets, carrying plastic bags of groceries. There were even small fruit stands still standing. I guess only foreigners get mugged.  On the roads, especially on the highway, people were waving their hands to hail rides or the small public white buses. We arrived at Veiki’s guesthouse which is just a seven minutes walk down the street, up a hill from Baylor clinic. We each have our own room and share a bathroom. I feel very safe at the place; konwing that there is friendly guardsman and a serving maid situated at the front of the house each night. We immediately readied for bed because Dr. Stephanie Marton was picking us up at 7:30 in the morning on the next day.

10 hour flight, 12 hour layover, 11 hour flight, 8 hour layover, 1 hour flight, 1 hour drive, 10 hours sleep.

During one of those long legs of the trip (they are all a gigantic blur of “He’s Just Not That Into You” and cheese paste with bread), we all decided to leave the airport and explore London. Danielle and I discovered that, if you run (literally, we ran), you can see the entire city of London—Big Ben, Westminster Abby, Buckingham Palace, both parks, and Parliament—at least three times in an hour.

We did not, however, get to explore Buckingham Square. Just as we entered the courtyard, we became instantly aware of our surroundings in the midst of the anti-genocide protesters flooding the square. As Danielle and I looked at each other wide-eyed, we were both thinking the same thing—Rule 18 of the official BTB intern packet—“do NOT, under any circumstance, get involved in political demonstrations”. Phew, BTB intern packet saves the day, Take One. We quickly left, and were both thankful to stretch our legs after 10 hours of suggested airplane exercises.

We made it to Swaziland on a propeller plane that pulled right up to the front door of the tiny, welcoming airport. In a sure miracle, all of our bags arrived safely at the airport. They must be shaping up in preparation for the World Cup. Customs seemed to have a problem with our Lab-in-a-Backpack. My conversation with the woman at the check-in counter in Johannesburg went as follows:

South African Airways: “What is in the giant black box?”

Me: “Supplies for a medical mission trip.”

SA Airways: “What kind of supplies?”

Me: “Medical supplies.”

SA Airways: “What kind of medical supplies?”

Me: “Donations for the Baylor clinic in Swaziland.”

SA Airways: “What kind of donations?”

Me: “Free ones?”

SA Airways: “Mam. What is in the box?”

* At this point, I had used all of my “avoid actually telling her what is in the box” tricks, and decided to use my last resort—stringing together a bunch of long, confusing words in a sentence that makes sense only to a select few who know the projects well.

Me: “Oh, what’s in the box? Um… It’s an inexpensive, efficient design of ultraviolet Bilirubin phototherapy lights for the treatment of neonatal jaundice in developing countries, and a medical diagnostic lab-in-a-backpack that includes an oil emersion microscope, a hemotrcrit zipocrit centrifuge, a pulse oximeter, and a sphygmomanometer—basically, diagnostic and treatment tools designed in a global health technology-focused bioengineering class.” All in one breath.

SA Airways: *blank stare, and squinting eyes* “Oh… okay… You will be boarding at gate A38.”

No extra charge for a second bag. No $55 / kg charge for the 10 kg of extra weight. Boom, roasted.

After a wonderful night of sleep, we were greeted by the sound of sizzling sausage (hotdogs) and the smell of baked beans in the kitchen. Any food beats no food. We began our day at the clinic with a tour of the beautiful BIPAI COE facility. Baylor should be astonished by their accomplishment—I know I was. We spent the rest of the morning helping enter data about patients as they visited the adherence room, and then learning about screening at the clinic. They are able to use DNA PCR—known at the clinic as DBS (Dried Blood Spot)—to diagnose HIV in newborn babies, but must send samples to a lab in South Africa, and are not able to receive results for, on a very lucky day, six weeks. By that time the mother has been breastfeeding for six weeks, and may have transmitted the disease to the baby. So, they have no way of confirming that the child does not have HIV until 18 months, according to Dr. Marton.

With their own CD4 machine and their highly trained staff, the BIPAI clinic is doing an incredible job of treating patients, not just HIV. Many “HIV Reactive” patients must also be treated for tuberculosis, malnutrition, malaria, or even cancer. The clinic does much more than just hand out drugs—they are certified to treat TB, they council families, they monitor adherence, they treat for free, and they consider the patients’ circumstances. As a Haitian proverb declares, “Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.”

In Swaziland, grandmothers are called “gogos”. Today, I met an incredible woman. I will call her Gogo. She was at this clinic with the last of her five grandchildren, all born within the past year, and all in her care—two sets of twins, plus one more. Just when a woman thinks her work is done, she becomes a grandmother. As Gogo threw the baby on her back and began to tie her in with a blanket, we laughed as she joked about teaching me how to tie a baby to my own back. I said “Not quite yet, I’m only twenty, just a baby myself.” She asked me if, in the United States, grandmothers take responsibility for their children’s children when they get a girl pregnant at age 18, as her son had. I said not often—we have many resources in the United States. We laughed, but it wasn’t quite funny. I guess all suffering isn’t quite equal.

The afternoon was quiet, and Yiwen and I were glad for a break. I played the high-five game with a 5 year old boy for about an hour—you know, the game where sometimes you let him give you a high five, and sometimes you pull your hand away and say “Too slow!”. The game seems to entertain children of all ages and types—from the hematology/oncology clinic at the Texas Children’s Hospital in Houston, Texas to the BIPAI Clinic in Swaziland, Africa, the high-five game is a win. Lucky for me—it’s the only game I’ve got.

After several explanations about President Obama, the economic crisis, and the working-class American, we finished our day at the clinic. Hotdogs for breakfast, birthday cake for lunch, Nerds for dinner—we needed to buy some food. Africa, anyone?

I apologize for the delayed posts—we have little to no internet access in Swaziland. Hopefully, pictures will come in a month. Yiwen and I will be in Swaziland, Africa at the BIPAI (Baylor International Pediatric AIDS Initiative) Center of Excellence for the next 5 weeks, before we head to St. Gabriel’s Hospital in Malawi.

Swaziland is a beautiful, mountainous, land-locked country in north-eastern South Africa. The country has one of the highest HIV prevalence rates in the world, and has an infant mortality rate of about 69 deaths / 1,000 live births.

The BIPAI Center of Excellence was launched in Mbabane on February 24^th, 2006 with a mission to provide children, parents, and siblings with antiretroviral therapy and follow-up care, to build a support system of local clinicians, and to establish HIV/AIDS outreach services. To say the least, the clinic is well on its way to achieving its goals.

Yiwen and I will have two major goals to accomplish during our five weeks here—first, to support the clinic’s mission by working on several projects assigned to us by Dr. Stephanie Marton (more about that later), and second, to increase access to basic diagnostics and treatment in the area.

Specifically, we have four projects that we hope to incorporate into our visit at either the BIPAI COE clinic in Swaziland, or at the hospital in Malawi:

1. Medical Diagnostic Lab-in-a-Backpack—The main purpose of this hiking backpack is to provide fast, basic diagnostic health care to inaccessible villages. All of the tools in the backpack can be battery-powered and solar-charged. The backpack contains all of the essential medical equipment that a physician in the field might need, including an oil emersion microscope, a centrifuge, an otoscope and ophthalmoscope, a glucometer, urinalysis strips, a pulse oximeter, essential first aid supplies, and several other diagnostic tools. Our goal is to test, evaluate, and provide feedback for further development of this project.

2. Community Health Worker (CHW) Screening Kit—The purpose of this backpack is to equip community health workers (CHWs) with tools for providing basic first aid care and diagnostics. The backpack contains several tools to be used in rural communities, including: pregnancy tests, a scale, first aid supplies, urinalysis strips, and several other tools. The CHW Screening Kit differs from the Medical Diagnostic Lab-in-a-Backpack in that the Lab-in-a-Backpack is designed to be used by physicians, while the CHW screening kit does not require professional training for use. Our aim is to train CHWs to utilize the tools of the backpack and to assess for future additions.

3. UV Bililights—The UV Bililight is an inexpensive device used to treat neonatal jaundice. This condition is common in upwards of 70% of newborns. The device that we have brough costs less than $50 to build, and uses simple circuitry components such as blue LEDs to reach standard efficiency. Our objective is to test the efficiency and sustainability of self-constructing the device in a low-resource area.

4. Incubator—The incubator is an economical way to provide an ideal, healthy environment for newborn babies. Normally, incubators and phototherapy treatment units costs $1500 – $2500, require high maintenance, and are therefore unaffordable in developing countries. This design can be built for less than $50, and relies on four light bulbs. This project has potential for microfinance collaboration; however, our goal is to train locals to build the incubators and evaluate future improvements.

Dr. Marton has already suggested several projects for us to get started on around the clinic, including organizing their resource center, developing a system for tracking x-rays, and fundraising for their teen club.

Now that our projects have been introduced, I should say a few things—I am enormously thankful for the opportunity that has been provided by Rice University Beyond Traditional Borders, Baylor International Pediatric AIDS Initiative, the Howard Hughes Medical Institute, and everyone else who has contributed to the funding of this internship. Service depends on support. From the bottom of my heart, thank you.

“Praise the bridge that carried you over.”

-George Colman