Reports from Swaziland

It’s amazing how time flies in Swaziland; after this past weekend, Z and I calculated that we only have one free weekend left before we leave. Unfortunately, as she will talk about in her blog, Z became really sick this past Friday evening; a bacterial infection—which we suspect she received from a slobbering kid during reading time—hit her hard and fast, forcing us to move her to the private Mbabane Clinic for treatment on Saturday. Again, we are fortunate to be surrounded by so many great doctors. We actually woke Dr. Michelle up at 6:30 because Z just could not take the diarrhea, vomiting, fever, chills and migraines any longer. Then Michelle stayed to make sure Z got the exact IV medicine and antibiotics she needed. The adventure was a scare, but it was a great relief to see Z recover as fast as the illness came.

Z’s adventure was an unpleasant way of seeing the capacity of the private health sector, but it is impossible for me to not draw a few comparisons between the private and public sectors, given now that I have seen both. The big difference is, of course, money. A hospital bill at MGH for a few overnight treatments is around the lower hundreds. A one-day stay at the Mbabane Clinic (Z’s experience) is right now unknown but at least 2000 rand, probably 4000 rand. The clinic makes sure the impatient can initially afford the price by asking for an initial deposit of 9000 rand!

In terms of service, both establishments offer much the same. The blood chemistry labs are done by the same company. The same diagnostic tools are used. The same drugs and medications are accessible. The doctors’ expertise and dedication to the patient are the same.  Actually, I admire the MGH physicians more because they are not only great doctors who are flexible in a more resource-limited setting, but also devoted teachers. Tagging along two times on the morning rounds with the rest of the nursing students, I have learned so much in medical knowledge, medical analysis and obstinate determination. In an especially puzzling case of hydroencephalitis of unknown origin in a HIV-positive boy, the MGH doctors’ dedication to unearthing the cause—after multiple inconclusive tests– before giving ARVs (the recommended treatment) was truly venerable. They are the diamonds in the rough. I would trust them to treat me. The extra money charged by the private clinic, seems to me, goes toward only a private room with a television in a fancy building.  

Okay, there is probably another difference between private and public: the availability of pulse oximeter and a vital sign monitor. The private clinic has some units of automated blood pressure cuffs and pulse oximeters hooked up to a monitor that would provide a reading of the vital signs. I have not yet seen one in MGH.  However, the quality of the technology in the private clinic is questionable.  The pulse reading for Z was always erratic, ranging from 70 to 180 (when she was lying on the bed?). Her blood pressure reading was also doubtful, being 112/49. I think all this highlights the fact that that there is a serious need, in this country at least, for vital sign + oxygenation monitors that we see so often in the US. When I mentioned this to Dr.Stephanie, she admits that pulse oximeters are badly needed in Swaziland.

Today, I spent half of my day in MGH. The plans for this week for MGH have changed a bit. Discussing the project with Dr. Akingba (head pediatrician whose name I finally mastered) and Stephanie, we decided that it was best  and proper to first present the devices to the Senior Medical Officer (SMO) who is in charge of the hospital’s entire operations. I was lucky I managed to obtain an appointment with her this week; I will be presenting on Friday morning!  (at 8 a.m. no less) Tomorrow, I am going on my first outreach trip with Dr.Erin to another hospital, which the PAC doctors think would be receptive to the bili-lights and the incubator.

What was most memorable about today was the two hours I spent shadowing Dr.Dlangi (I am not sure I am spelling his name right) on his morning rounds in MGH. EVERY case we saw was malnutrition—which can then easily lead to deathly fever, diarrhea, and illness. Why the ubiquity? A textbook answer would point to poverty and education. Dr.Dlangi showed, through careful family history examinations (now I know why they are important), that the main reason(s) are actually quite different, at least in this country. Reason one: HIV. It can pass through breast-feeding. For at least the first six months of an infant’s life, the mother’s milk has everything the baby would need. When HIV-positive mothers are advised to stop breast-feeding their children, counselors often forget that breast milk is often the baby’s only source of food and protection. Babies not on the mother’s milk are five times more likely to develop fever, diarrhea, malnutrition than their counterparts. Mothers on ARVs with a CD4 count above 350 can breast feed their infants (abet with a small risk from 5 to 20%), but the safest way is to actually boil the breast milk to kill off the virus before feeding the baby. Because boiling is time-consuming, this is unfeasible, but I think it would be a hard, but worthy design project to find a way to easily boil breast milk or make it safe to drink. So many malnutrition cases would be avoided.

Reason two: socioeconomic constraint. Most mothers have a job that puts food on the table for the family. There is no concept of maternity leave, especially a paid one, here. Most mothers must go back to work immediately after giving birth, which prevents her from adequately breast-feeding the child. Hence, the malnutrition. It was really amazing to see that all the cases we saw switched between the two reasons.

I will end my blog with an interesting quote from Dr. Dlangi. (I really admire him. His breadth of medical knowledge and experience is astounding. He never fails to raise the questions of why or stray off into the world of medical politics.) His reasoning for the current African world of medicine, politics, society and economics is that–to half quote, half paraphrase– “the white men view people as asset;, the black men see them as liabilities.”