Reports from Swaziland

For the past few days, I have been working with one of the PAC doctors, Michelle. As the story often goes—she has an incredible grant, an incredible idea, and is working on its implementation. Alone. Early Infant Diagnosis (EID) was introduced in Swaziland in 2007 (see previous post) in 10 hospitals and health centers. 2372 infants were tested using DBS DNA PCR testing (see previous post), and 461 (19%) tested positive. Since the roll-out to 42 rural health centers and clinics from March-August of 2008, an additional 4200 DBS tests have been completed with 482 (12%) positive results. Although DBS is identifying more positive children, only about 50% of infants are actually returning for results. So, while almost 1000 children are receiving early diagnosis, only half are being referred for care and treatment. As discussed previously, mortality decreases significantly with early initiation of ART therapy, and it is vital to close the gap between testing and linkage to care.

As the lead partner in DBS training and roll-out in Swaziland, Baylor has an opportunity to look for strategies to strengthen links between diagnosis and treatment. Many of the outreach clinics are utilizing expert clients (see previous post—openly (+) translators) to initiate counseling and follow-up with exposed infants. They hope to expand the role of the expert client to focus on tracking patients with positive results and linking them with HIV care.

Michelle has been given a grant to provide 20+ outreach ARV clinics with cell phones and “airtime” in order to communicate with HIV (Reactive) mothers who bring their newborns in to the clinic for DBS DNA PCR tests and never return to receive their results. Her program, “Swaziland COE Early Infant Diagnosis Follow-up and Linkage to Care Program”, was launched at 8 outreach clinics about two months ago and will launch at 20+ sites next year.

In Swaziland (and in most of Africa), it costs a tremendous amount of money to make phone calls, and costs next to nothing to send a text message. Right now, the expert clients are calling the mothers, sometimes five or six times, in order to remind them to pick up their test results. Needless to say, they could benefit from a cheaper, text-message based communication system. Insert FrontlineSMS (www.frontlinesms.com). Using this system, the clinics could communicate with the labs in order to give patients their results while they are in the clinic for their monthly follow-up appointments, mothers (or CHWs) could be contacted when their results are available, and records could be kept of follow-up attempts for a retrospective analysis of the implications of the project. This is a work in progress—hopefully, more will come soon.

Yiwen and I now spend about an hour a day re-learning our colors, shapes, and opposites. We have started a reading program with the patients in the waiting area of the clinic. From 10am to 11am every day, at least twenty kids pile onto our laps while they “read” to us. By “read” I mean:

-Find the banana, ball, and kite in the picture

– Slobber all over us

– Discover that dinosaurs do, in fact, look like giraffes

-Sneeze all-out right onto the marble floor

-Count every house as at least four or five houses

-Pee on my leg

Needless to say, I’m pretty sure I now have (at the very least) TB, scabies, and ringworm. All said and done, the initiative is going very well. We have finished the resource library project—the executive director of the clinic walked in while we were making our finishing touches and sighed, “At last, I see some reason in this room.” We are now spending a few hours a day working on organizing their x-ray system, and creating a curriculum for the Teen Club.

My favorite part of the trip so far has been the random moments of hysterical laughter. Last night, Yiwen was the source. We had spent all of dinner discussing our favorite movies with a Somalian guy living at the guest house. We discovered that he was one of only .003% of the world’s population who had seen ALL of the Star Trek episodes. Despite his obsession with Star Trek, and his worn-down World of Warcraft sweater, we ended up having a pleasant conversation. We discussed Batman, Slumdog Millionaire, The Notebook, Rambo, and pretty much every other popular movie we could think of. Just as we were washing the dishes, and the boy was going to sleep, Yiwen looked at me with a look of confusion on her face, and said, “Did Stephen Spielberton really direct Titanic?!”. After laughing hysterically for at least a few minutes, I informed her that, in fact, neither Stephen Spielberton nor Stephen SPIELBERG directed Titanic. It was James Cameron. I will now laugh before every Stephen Spielberg movie that I see for the rest of my life. Thank you, Yiwen.

I am so happy, ecstatic and excited that both Z and I have made some great progress in terms of the projects we brought to Swaziland in our second week here. Earlier this week, on Monday, Z and I showed the bili-lights, the incubator and the diagnostic-lab-in-a-backpack to Dr.Stephanie Marton to elicit her opinions on how to jumpstart the projects. She was enthusiastic about everything; it was so amazing—and a great relief to us– that she offered up front, voluntarily, to help us collect the evaluation forms we brought for the projects and gather any feedbacks to send to us after we leave, since she will be staying here ideally until next summer. I have seen Dr.Marton’s work ethic, her generosity and her sense of responsibility, so it is really reassuring to know that we have a reliable contact in Swaziland, one who can check up on the projects after we leave. Moreover, Dr. Marton, or Stephanie as I will call her from now on, also helped us carve out a time at the weekly doctor’s meeting on Friday to formerly present our devices to all the doctors and the clinic’s management team. I am sure we will receive more help and advice after that.

Specifically for my area of the projects, the bili-lights and the incubator are not applicable to the clinic because it doesn’t have the capacity for in-patient overnight stays. So, Stephanie recommended that I tag along with her on her weekly trip to the Mbabane Government Hospital (MGH) so that I could see and assess the need for the devices there. I just finished my trip and this same day, Z went on her first outreach trip to see if the lab-in-a-backpack would be of use in that area.

Up front, I want to say that my visit to MGH was a great experience, an opening view of the current condition of the health care system in Swaziland. I will separate my trip into two parts: project related topics and my general impressions of the hospital. In the former, I received a promising jumpstart. Stephanie introduced me to the head pediatrician whose name I unfortunately cannot spell right now. When I gave him a brief description of the projects in the children’s ward, he immediately took us to see the Maternity Ward where they isolate the neonates. It was a refurbished section, so the area was in a much better condition than the rest of the hospital. It still smelt of paint. They tried to keep the ward as sterilized and as clean as possible; we were not asked to take off our clothes when we entered the dark and extremely warm room, but we could only observe ward at the nurses’ station. The mothers, who were in the room, breastfeeding the infants, were in nothing but towels.

 It was a very interesting ward, not yet fully furbished, kept at an almost stuffy, sweltering temperature of what I would guess 37 degrees Celsius. The room was very dark, with the heavy blinds shielding the windows in the middle of the day, so that the only major light actually came from a running phototherapy unit emitting white light. I was surprised to see white light being used because blue light phototherapy has been clinically proven to be the more efficient and effective treatment. I learned later that the hospital did not have access to the latter. In fact, most of the equipment we saw in the room—the two incubators, the one phototherapy light, the plastic baby bens—were donated. The hospital had no means of maintaining them and once they are broken, there will be no one to fix them. Moreover, the equipment was just not enough to adequately meet the demand of what I saw to be at least seven babies. In gist, though the ward was somewhat technologically advanced and equipped, its appearance belies the emptiness of promises: the technology doesn’t meet the current situation and once they are run down, what will happen?

Sad, but hopefully true, the simple, low-cost and easy-to-maintain bili-lights and incubator might be the answer. The head pediatrician was very receptive toward the projects, provided—he said jokingly or perhaps not so much—that they are free. That was the least of my worries right now because I was initially afraid of possible policies or initial hesitation or distrust of new technology that would prevent the two projects from even being used.  I am excited and a little intimidated that I will be formerly presenting the projects next Monday and Wednesday to the hospital’s management officials and doctors for the final verdict. If the initial implementation is successful and well-liked, I hope that Z and I can teach the Teen Club members (started and supported by Baylor clinic) to make the incubators and sell them to the hospitals because the club—which Z and I will be helping in the coming weeks—is in dire need of funds. Wish me luck!

Sidenote: Stephanie recommended me another site where she thinks the devices could be useful. I will probably have a chance to explore it next week!

I love love Swaziland’s weather right now, just after its rainy season. The sky is always a pale cerulean expanse, sparsely populated by thin, wispy clouds. The sun is overhead, but it nothing more than a soft, warming pat on the back as the temperature oscillate around the 70s F. it is hard to call this winter, especially when I can hear the incessant cricking of the crickets at night.

Living here reminds me a little of my childhood in a rural part of China. The only paved roads are for cars. People walk along rocky dirt paths beside the road, unconcerned of the cars whipping pass them. Trash litters here and there, collecting in small valleys of dirt or drifting in circles with the breeze. It is curious that the trash is rarely a cigarette bud; there is almost no smoking among the native population. Small houses with formidable yards dot the landscape randomly, mostly in lower grounds but also situated in pockets of forest clearings up on the mountains. Whereas in China, families used the yard to farm daily vegetables, here the yards are paved for driveways and parking spots.

The people overall appear surprisingly wealthy, noticeably especially in the way they dress. It is a wonder to me to see the women walk up and down the steep hills in high heels and sandals. Interestingly, Z and I have not seen a single beggar; everyone seems to hold some type of occupation whether it is being a guardsman or a housemaid. This is the Mbabane, the capital; I am curious to see if the rural areas the clinic outreaches to match well with the city. At the same time, I am doubtful of the country’s manufacturing ability. So far, all the randomly picked packaged goods that I have bought from the supermarket—from water to olive oil—are imported from other countries, mostly South Africa or Europe.

The locals treat us with the same curtsey as they would afford to others, although we do get more solicitors for business. There is more Chinese exposure here than I had expected; I have received several “thank you” in mandarin and gestures of kung fu. Later, I learned that there is actually a Taiwan embassy here.

There is a substantial amount of foreigners here. It is easy spot a few groups at the market place, almost always accompanied by running children. It seems to be popular to start families here. Everyone is very friendly, waving or greeting a casual hello without even knowing who we are. A middle age man actually approached us and chatted with us after reading Z’s Rice Soccer t-shirt from afar. Rutti, the man, has actually returned to the village he had worked in as a peace corp volunteer and has been teaching there for the past six years. He was such as friendly fellow who actually invited us to dine at his house, if there was ever an empty weekend in our schedule. Z and I are very tempted to take up on his offer, after hearing that his house is a short walk away from waterfalls.

Saturday night was to say the least a very interesting night for Z and I. it was the night of Veki’s party, or as we found out, a Serbian man’s 30^th birthday party. I can only describe the party as unique, fitting for Swaziland. There were mismatched food, mismatched people, mismatched music that all seem to blend and mix seamlessly together. Drinks—pina colada, tequila, rum—were flying (Z and I sticked to coke), music was blasting, people were dancing in the living room. It was a fun atmosphere and we meet so many random people from all different walks of life. The question of how the heck did these people came to Swaziland simultaneously popped up multiple times to Z and me as we traded looks. We meet a Fulbright scholar, an English man heading the government’s irrigation project, a man working on the new airport, a woman who heads a catering business, Italian girls who work for the UN and many more, more than we can keep track of. They come from many countries—Serbia, London, Mozambique, Cambodia. The age range in the room spreads from the youngest of 3 to the oldest of 75 (A Holland man who has lived in Swaziland for 26 years).  We were a mismatched bunch, but in this setting, in this context, we were all friends. Many of the elders have actually traveled to many places and lived in Swaziland from quite some while. It was really interesting to listen to their perception of the Swaziland’s HIV problem, not from an American’s education perception but from one who has lived in this land. Talking to the irrigation head (lived here for six years) and the Mozambique native, we learned that they don’t believe that the Swaziland HIV problems is at all related to the king’s number of wives or the legalized polygamy. The king’s tradition multiple wives is actually a way for him to stabilize the nation’s clans. They think the HIV epidemic lays in the often wild and unbelievable attitude towards HIV. For instance, an acquaintance of theirs gave a lift to a woman one night and learned that she was a prostitute who knew that she had HIV/AIDS and that she would die in a year or so. Her attitude to the situation was that, if she was to die soon, why not enjoy life– aka spread the virus…We heard more accounts of the general uncaring and ignorant attitude to HIV the two men have encountered in Africa, but they all serve to highlight one fact: there is still much to be done about HIV awareness and education in this continent.

 The party, though fun, felt interminable, but we were eventually rescued around one, driven home red-eyed from the ceaseless smoking that went on, sleepy to the bone but refreshed from the new perspectives we gained.

In Swaziland, approximately 15,000 children are living with HIV/AIDS, and there are approximately 54,000 AIDS orphans. Swaziland’s infant mortality rate, at 69 per 1000 live births, and the under-five mortality rate, at 120 per 1000 live births, have doubled over the past 15 years. HIV related mortality contributes significantly to both the infant mortality rate and the under-five mortality.

There are approximately 40,000 infant births each year, and with the antenatal HIV prevalence at approximately 40%, this results in 16,000 HIV-exposed infants per year in Swaziland. There has been a recent focus on the early diagnosis of HIV in infants and children less than eighteen months of age.

There are two different categories of tests used to diagnose HIV: antibody (indirect) tests and virologic (direct) tests. Antibody (indirect) tests include a rapid test, ELISA (Enzyme Linked ImmunoSorbant Assay), and Western Blot tests. Virologic (direct) tests include DNA PCR, RNA PCR (viral load), and P24 antigen testing. The tests available for early infant diagnosis in Swaziland are the rapid antibody test and the DNA PCR virologic test.

A diagnosis of HIV can be made as early as 4 weeks of age, using a polymerase chain reaction (PCR) assay that directly detects the presence of HIV DNA (not just the antibody). DNA PCR was introduced in Swaziland in February of 2007 at all of the 6 major hospitals (Mbabane Government Hospital, Raleigh Fitkin Memorial Hospital, Good Shepherd Hospital, Piggs Peak Hospital, Mankayane Hospital, Hlatikulu Hospital, and the Baylor Children’s Center of Excellence). The dried blood spot (DBS) technique is being used for DNA PCR testing, allowing for convenient blood collection and stable transportation of samples.

In areas where DNA PCR is not available, the rapid test that detects antibodies to HIV is commonly used. The rapid test poses difficulties in diagnosing HIV in children less than 18 months of age, because infants may still have maternal antibodies to HIV that cross over to the baby through the placenta during pregnancy. The maternal antibodies can persist in the infant’s blood for as long as 18 months. So, even if a child under 18 months is not infected, he may still have a positive rapid antibody test result, due to the presence of persistent maternal antibodies. While the rapid test can detect HIV exposure, it cannot be used to definitively diagnose HIV in infants and children less than 18 months.

Although the antibody test cannot definitively diagnose HIV infection in infants under 18 months of age, it can be useful for identifying potentially uninfected infants as early as 9 to 12 months of age, IF they have not breastfed or if they stopped breastfeeding at least 3 months before the antibody test. Virologic testing is necessary for a definitive diagnosis of HIV before 18 months.

DNA PCR is most accurate after 4 weeks of age (>98% sensitivity). According to Swazi protocols, all exposed infants should be tested for HIV with DBS DNA PCR at 6 weeks of age, or at the earliest clinical encounter before 18 months of age, regardless of their feeding practice. Unfortunately, the process of DNA PCR testing in the laboratory is labor-intensive and expensive, so rigorous quality control must be in place in order to receive accurate results.

HIV-infected infants are at increased risk for rapid disease progression and early death. Without treatment, over half of infected children will die before two years of age. Early diagnosis for HIV exposed infants using DNA PCR testing enables health care workers and mothers to initiate appropriate prevention, care, and treatment services to infants. Early treatment for infants and children improves their chances for survival, decreases infections, and increases their quality of life. Early HIV diagnosis can guide care and treatment and inform decisions on contrimoxazole prophylaxix, CD4 and other laboratory evaluation, and antiretroviral treatment. It can also assist health care workers in reinforcing important infant feeding recommendations.

PMTCT (Prevention of Mother to Child Transmission) programs have found that the antibody test used at 18 months was inadequate for clinical monitoring, due to high rates of mortality among HIV-positive infants, and lack of documentation of HIV exposure status after 18 months. Early diagnosis of HIV through DNA PCR testing at 6 weeks of age can give more accurate data on the impact of a PMTCT program.

That is, of course, if the test results are actually received at 6 weeks of age. Here’s the catch: DBS samples are being collected by trained health care workers at various facilities throughout Swaziland (including the BIPAI COE), and sent to the hospital that has been designated their “hub”. Each hospital then collects all of the samples received from facilities in their region, and transports them to the National Reference Laboratory (NRL) in Mbabane Government Hospital. Samples from throughout the entire country are then collected and sent to the testing site at the DNA PCR laboratory in Johannesburg, South Africa (NICD- National Institute for Communicable Diseases). The results then have to make their way all of the way back to the National Reference Laboratory in Mbabane Government Hospital, and then on to their respective Point of Care providers. This all takes, at the very least, six weeks, and costs $20 / test. By the time the mother and child have received their results, the child has been breastfeeding for another six weeks, and must receive yet another DNA PCR test in order to, again, confirm the absence of HIV in the baby. Realistically, no baby can be declared HIV FREE in Swaziland until 18 months of age.

What will it take to bring infant HIV testing to Mbabane, Swaziland? Here are a few ideas that I have come across (by far, my favorite is #3):

1. An experiment done in Cambodia by Janin Nouhin and Marie Nguyen showed that “boosted-p24-antigen profile assay, with performances similar to viral cultures and costs similar to DNA-PCR, is easier to perform and could readily be set up in resource-poor settings.” Although the p24 antigen test is NOT recommended for infant testing, due to its low sensitivity in babies, these results show that perhaps a boosted-p24-antigen profile assay could be the answer.

Source: http://www.ajtmh.org/cgi/content/full/75/6/1103

2. A study done in Argentina showed that centrifugation improves the detection of HIV p24 antigen in the plasma of infants born to mother infected with HIV. The aim of the study was to improve the sensitivity of the detection of p24 by centrifuging the plasma. The results showed that “centrifugation of plasma samples prior to determination of p24 in pediatric patients resulted in a significant increase in sensitivity.”

Source: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T96-4VH2GMD-3&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=dfa8392ae81ffcbca9bd7be96fccbd6c

3. Pocket-size PCR Machine: This machine is “a novel thermocycling system capable of performing high-speed DNA amplification via the PCR in a simplified, inexpensive and portable format. The advantageous features of this technology include an inexpensive hardware platform which can be build for approximately $10 (compared to the estimated cost of $2500 in 2004), timescales of the order of 10-20 minutes (presently over 1 hour), no moving parts, no external fluid transport beyond sample loading and unloading, requires little or no modification to existing reaction protocols, portability and small size (using 2 AA batteries). It is ideally suitable for performing PCR based assays in situations where a yes-no result is desired and an extensive laboratory infrastructure is lacking.”

*Seems too good to be true, right? I’ve emailed the professor at Texas A&M in hopes of obtaining more information.

Sources:

http://otc.tamu.edu/technologies.jsp?casecode=2418TEES06

http://www.rsc.org/chemistryworld/News/2007/May/01050701.asp

If anyone knows of other solutions to this issue, please leave a comment. Lesotho guys, what is the DNA PCR status there? As of now—we have identified the turnaround time of HIV DNA PCR results as a substantial concern at the Baylor clinic in Swaziland, and are considering several existing solutions. Perhaps this would be a decent project for students at Rice. What will it take to bring quick, inexpensive, simple HIV testing to newborn infants in developing countries? Perhaps this idea is a little ambitious. Perhaps I still have quite a bit to learn about DNA PCR.

We are having a BLAST with the medical team here—a mixture of pediatricians, family doctors, infectious disease doctors, MSF doctors, Swazi doctors, South African doctors, residents, medical students, nurses, and “expert clients” (openly HIV positive translators and counselors). In the midst of our projects, we have had a chance to spend a few hours a day in the clinic with the doctors. We have encountered some really cool cases—some of them, “unheard of” in the US:

1. The first of the hidden gems was a patient with epilepsy, MDR (Multi Drug Resistant) TB, and HIV. She had an ENORMOUS pleural effusion caused by her TB. A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. So, needless to say, she was having serious trouble breathing and could barely stand up straight. Pleural effusions can be easily drained, a standard protocol in the US. However, this woman refused to go to the hospital to get it drained.

“Patients believe that you go to the government hospital to die. It’s mostly true—we send patients there as a last resort. Whenever we tell a patient that they must go to the hospital, they always begin crying hysterically.”

Needless to say, this patient was no different. The doctor examined her chest to reveal a scar where a traditional healer had attempted to treat her condition. The woman was unphased by the fact that her x-ray showed no function of her left lung—a cloudy white haze. She refused treatment, claiming that draining the lung would cause it to harden, and that she would surely die from the wound. After an hour of convincing her that she needed to have it drained, the doctor agreed to drain the effusion at the clinic. Yiwen and I watched as they drained 250+mL of fluid, teeming with TB.

2. There is only one oncologist in all of Swaziland—he’s from Cuba, and he only does mastectomies. There is no chemotherapy or radiation in the entire country, and there is little to be done at the clinic for patients with Kaposi’s sarcoma (often, an AIDS defining viral cancer).

“This is a serious issue that goes beyond HIV related cancers.”

They need an oncologist. Currently, there is only one oncologist on the PAC (Pediatric AIDS Corps) team, and he is located in Botswana. The cancer scene is quite a contrast to the 14th floor of the Texas Children’s Hospital.

We have identified several potential sites for the bililights and/or incubators:

1. Orphanages: The clinic does outreach trips to several orphanages that may require neonatal care. We will be visiting the orphanage (hopefully) once a week.

2. The two government hospitals (Mbabane Government and Manzini Government): The hospital in Manzini has just set up a neonatal care facility and will likely be able to make use of the projects.

3. Outreach clinics: The Baylor clinic sends about 5 of its 10 doctors to outreach clinics every day. We will be traveling with one of the outreach doctors once a week.

We are finishing up the resource library, and are beginning a few other projects around the hospital this week. This afternoon, we will be presenting the Lab-in-a-backpack and the bililights to the hospital staff. We spent Sunday evening desperately holding the bililights together as we waited for the Epoxy glue to dry. Yiwen’s worst fear had come true—the side boards began to crack off on the flight over.

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.