First Week
Despite being here for less than a week, we have settled into a semi-routine. We wake up at 6:45, eat our breakfast and walk down the already buzzing street of cars and students to the Baylor clinic by 7:30 (or try to). Z and I use most of the early morning–when patients are just trickling in–to work on the tasks Stephanie asks our help on. By noon, the clinic is in full-blown action, which gives us the opportunity to shadow the various doctors.
Shadowing–getting to know–the doctors and the visiting scholars in the clinic has been an amazing experience. Most have finished their residencies and after hearing their life’s experiences, of what lead them to Swaziland, Z and I often looked to each other in wonder. They have lived and are living such full-filling, balanced lives in terms of not only academics, but also service and family. Each seems to have devoted a few years to service-based programs like Peace Corps, lived in many places, enrolled in great programs like the National Health Service Core that would pay for medical school in return for service and started up families. It’s a great feeling to work with a close group of people who have done so much and are doing the things I want to do in my future. The doctors are a friendly bunch; just on Thursday, we were invited to a celebratory dinner for a couple that will be leaving the clinic and another who has successfully adopted a Swazi baby after six months of difficulties. I was grateful for the invite, especially since it would interrupt the established routine of spaghetti dinners Z and I have and will continue to have throughout our stay here.
In these few days, I have come to know the layout of the clinic with the familiarity of an old friend. I know which restroom best to use, where to store my stuff so I don’t lose it, which doctor can be found where. Z and I also had the chance to self-explore the clinic laboratory. The lab is equipped with a CD4 machine which, as the Swazi technician explains, basically applies the ELISA method to detect the presence of lymphocytes expressing CD4 markers. The results can be obtained in a day or two. There are two other machines: a hematology analyzer that outputs the concentration of blood components and a “chemistry” machine that evaluate the electrolyte concentrations in blood samples. The lab seems to be well equipped with the essential technology to offer maximum HIV follow-up. However, a big question that comes to mind is that how the clinic can afford a CD4 counter but not a DNA PCR machine. Instead, the doctors must wait for at least six weeks to receive the diagnostic results from a lab in South Africa. Using current developing diagnostic methods such as the p24 antigen test is currently believed to be unreliable for infants, but it would save much time, effort, and inefficiency if we could bring a simpler, more portable, cheaper PCR tool for the clinic. One a good note, Swaziland just bought a DNA PCR machine a few months ago and is currently testing its general quality, accuracy and efficiency. I hope it will be ready for use soon.
Working alongside the Swazi staff is an interesting experience. I would almost call the staff, a family. You can see it in the way they seek each other out to greet one another, in their small exchanges as they pass each other in the hallways, in their laughter and jokes during their breaks. Their many breaks: at least a tea break around 11 that looks like lunch and then the official lunch break around one. I sometimes have trouble accepting their lose schedules but I admire that they always arrive to work early and on time. I myself struggle to wake up at 6:45 in the morning to arrive punctually, but when I step foot into the building, the staff are already there, arranging paper and preparing files for the patients who are already seated in the waiting room benches. It is a friendly, “lack-of-urgency” (as Stephanie likes to describe it) atmosphere of working, one that I find Z and I are slowly being incorporated into by the staff. I would be surprised to go to an office and not hear music playing. I was surprised just a few days ago, that the people here know and have Facebook. Cyclone, who works at data filing department, is one of our first Facebook friends. I also notice instances where it almost felt like a few would purposely seek us out to say hi or good morning to us.
Walking about in the clinic, it is easy to pick up a few things common about the patients. For one, no matter how much weight the doctor may say the kids have gained, I think the children are mostly malnourished. Their bulged tummy compared the rest of their thin limbs is the clear evidence. The staple diet in this country is a kind of porridge and beans. The porridge is a white mixture of salt, corn flour and water with a substance similar to that of mash potatoes. Not a very nutritious. (To our queasy stomach, Z and I also learned that chicken liver is a favorite dish here.) Second, not many men come to the clinic, neither to bring their children nor to get treated themselves. 99% of the time, we see maternal family members with the children. Yet, in reality, it is the men’s actions that greatly exacerbate the HIV epidemic. Men, in this society, can lawfully take multiple wives; they can conduct promiscuous activities when they are away from home; they can decide whether to use a condom or not. The fact that their presence is lacking in the clinic highlights a haunting note of the future: we can offer the best, free treatment to all the HIV victims of the world, but if the propagators do not change their ways, HIV will continue its cycle of pain, death and destruction. On a happier note, despite the clinic being only a few years old, the adherence of the majority of the patient is quite high, above 95%. I see the silver lining in the continuous and increasing numbers of people who enroll in the clinic, who are serious about treatment, about improving their lives and about saving the lives of innocent child victims.
A great highlight of this week goes to a special case that happened on Thursday afternoon: a lung effusion tap rarely seen even in the US. A lady came into the hospital with her elderly mother. A cursory glance could immediately show that something was gravely wrongly with the lady. She could barely walk ten steps without stopping to lean on a door or wall to rest. Her breathing came in small hiccups and her hands clutched tightly around a tissue paper to constantly wipe away her painful tears. It turns out that she has a serious case of TB, mostly due to her low adherence to ARVs (about 70%). It was about two weeks ago that she started on TB medication based on a x-ray where more than 2/3 of her left lung came out as white when it should be black—two-thirds of lung was already filled with fluid. During this visit, we knew that the lung edema was worse because she hadn’t been taking her TB medication religiously because, she says, it reacts with her seizure meds to cause her to faint. What was interesting about this case, to Z and I, is the indigenous perceptions about western medicine and current Swaziland health system that make this relatively simple medical case harder than it is to treat. For one, the lady was advised two weeks ago that she should check herself into the government hospital for an effusion tap to drain the fluid, but she refused. Her family was afraid she could die, either from the wound because the lung would not be able to heal itself or from the lack of fluid that will make the lung winkle up. Two very wrong conceptions that caused her two weeks of pain. Moreover, she cried even harder when she was told that she must go to the government hospital (life or death situation), a common reaction, Dr.Amy informed us, because so many patients do actually die in the government hospital from the poor health service. No one wants to go to the government hospital. We ended up making a compromise to drain as much of the fluid as we can using the clinic’s rudimentary equipment. It took about three to four tries—of inserting three inch long needles, sinking each all the way to the tip, twisting it this way and that—to find the right position that would drain the thick, yellow fluid (about 250 ml in total). I think this case really illustrates the point that treatment must go hand in hand with education in developing countries. There must be a level of understanding and trust between the patient and the medical establishment; or else, no matter how good the treatment, it would fail.