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.