Reports from Swaziland

Wednesday night, I arrived home in one piece after four exhausting flights from Matsapha. I had the opportunity to watch the women’s world cup final match with my family yesterday afternoon, where a grieving Japanese team beat the US to win their first ever world cup title. Though I have not had a chance to really follow the women’s world cup from Swaziland, I read about both teams to get a better picture of the matchup. It seems that Japan was really not a spectacular team, having lost to this same US twice before. They came in to the match the underdogs, yet in the wake of their nation’s troubles, they rallied to win a game that has become a beacon of hope to Japan.

Watching the match, I could not help but think of the kids in Swaziland where, even a year after the world cup, kids (and adults) still wore soccer jerseys and every once in a while, played vuvuzelas which we could hear across town.

Working at a pediatric AIDS clinic, I saw many children living through horrible conditions over which they had no control. While in country, I wondered how they could come to teen club and smile despite being handed an unfair shot at life. They did not show any outward bitterness, even though I knew many of them had a difficult time coping with the fact that they had HIV in a society where such people are regarded as second-class citizens, or even cursed. With so few opportunities afforded them, they still had their dreams and their faith. One of the boys I met wanted to be a pilot; another, a chef; and yet another, a teacher. I realized it was the same inner strength and the spirit that I watched in the teams today that was within these kids that kept them going.

I am so thankful for having had this opportunity to go meet these kids and to show them a little of God’s love in whatever small way I could. Amidst the economic crisis in Swaziland, I hope that the projects we worked on will be able to improve the quality of life for at least a few of these children and families even now that we are no longer there.

Thank you for following my blog. I hope you have been able to experience Swaziland with me through it.

Mantanga Falls

Having finished our last full week in Swaziland, we presented our work before the Baylor Clinic staff during the Friday Healthtalk. We explained that the COE was going to start using the dosing clips alongside the CHAI sponsored clinics and taught the staff how to insert and remove clips from the syringe. We will be working with the Baylor doctors this week to develop an ordering and tracking system for clip and syringe distribution in the clinic. Hopefully, the clinic will soon procure syringes so that clip distribution can begin. We will also try to determine what should be done with the extra Nevirapine and Kaletra syringes that come with the medications and will need to be removed before the medication is given to the patient with a syringe and dosing clip.

We will also be piloting the liquid medication dipsticks this week. During the presentation, I had one of the expert clients in charge of performing adherence come up and demonstrate how to use the stick and reading card, which she did with no problem. Hopefully, this will make her and the other expert clients more receptive to using them in clinic.

The extended charts are ready to go in case we get an appointment with the MoH. If not, we are hoping to submit them to the SNAP materials coordinator for further submission after we leave. Once we finish creating job aids for them, our projects will ALL have reached some level of completion!

Yesterday, we had the opportunity to see some cave paintings that were 4,000 years old – certainly the oldest paintings I have ever seen. The tour guide was a girl about my age who lived in the hills where the paintings were. She led us down a ridiculously steep path covered in loose rock in flip-flops! After explaining the paintings to us, she started asking us questions about ourselves. In turn, we wanted to know a bit about her. She was the first person I had ever met from a polygamous family: her dad had five wives. We found out that she had applied to go to the university and wanted to become a teacher. It was a pleasant surprise to hear that someone from such an outlying chiefdom even had the opportunity available to her. I really hope she is able to fulfill her dream.

Here is one of the paintings that shows something rare to find painted – a wildebeest:

While the past few weeks have consisted mainly of presenting our work before countless organizations, we had quite a change of pace yesterday. We finally had the chance to go out to some of the more rural ART (antiretroviral therapy) clinics and see how things are done there. On our way out to the sites, we came to a halt on one of the rural roads where three little piglets were following their mother across the road!

I spent my time yesterday at Mankayane Government Hospital with a representative from ICAP. We were able to train about six expert clients on how to use the tablet adherence charts that we have been working on during our time here. At the end of the day (which happens around lunch time), I asked for feedback on the charts and was surprised to see how receptive the expert clients were to using them. They did not seem to feel that the charts were too complicated and they wanted to have some made for 60-day and 90-day visits as well.

I have to admit that while we were working on the charts from the Baylor clinic, I was a bit skeptical about how much of a difference they would actually make on calculating adherence in rural facilities. But actually seeing them used in clinics (where adherence monitoring was not consistently done before), I realized what a powerful tool these charts can be – if providers are properly trained on how to use them and they are used consistently – in improving the quality of care given to patients.

Using the feedback we were given from the facilities, we created extended charts which could be used for 60 days and 90 days as well. We were able to present these charts to the director of SNAP (Swaziland National AIDS Program) just this afternoon and should have them on their way to the Ministry of Health (Forms Committee) soon, even though this is likely to happen only after we leave the country.

One very interesting thing about adherence that I did not previously think about was the support structure needed in order for a patient to have good adherence to ARVs. Many of the patients we saw had much better adherence to their morning tablets than their evening tablets because they would often fall asleep before the time designated to take them. Living alone, these patients did not have anyone to wake them or remind them to take their pills before falling asleep, exhausted from a full day at work. There was even one patient who broke down in the clinic because she felt so alone, without any real friend with whom she could even share the fact that she was HIV positive. This comes back to the barrier of having such a large stigma against HIV in the country, an issue that requires some creative thought indeed.

Finally, at the very end of our hectic day, we had our first opportunity to try some authentic Swazi food. From the cornbread-type cakes to the colorful wild vegetables to the stewed oxtail, the food was incredible, a welcome break from cooking our own meals!

Below are some of the expert clients being trained on how to use the adherence charts:

It has truly been an exciting couple of days. We had three meetings today, two of which were at the same time. Deepika was able to present our adherence materials to ICAP while I spoke with members of the Ministry of Health about the final versions of the family planning brochure and poster. The really exciting part is that I was able to speak with them about the adherence charts and the liquid adherence dipstick and reading card, and they gave initial approval to of them!

We also received an encouraging response from ICAP who asked that we extend the pill adherence charts to 60 and 90 days! We will be piloting the materials at the Baylor COE this week and be gathering feedback just before we leave.

While I was waiting at the Ministry of Health office for my driver to pick me up, I had a chance to speak with one of the members of the Health Promotions Unit. Since it was an unusually cold day, she invited me to wait in her office. We spoke about our families for quite a long time. She told me about how she was one of five children. When I expressed surprise at having such a large family, she told me that it was actually quite a small family. In a polygamous society like Swaziland, families may have up to 50 children!

One other thing she said really hit me hard. In the US, a family with two children is fairly common. But she made a conscious decision to only have two children. The reason was that had noticed during apartheid, when many South African families fled to Swaziland, and now with the influx of refugees from Zimbabwe, how difficult it was for large families to be able to carry the young children with them.

Even though Swaziland has been fairly stable, she and her husband decided that just in case they would have to uproot their family, they should keep it at a manageable size. This is definitely something I had never thought of when thinking about what size family I’d like to have. Listening to her, I realized how different people’s mindsets are in many other parts of the world where war and unrest are never that far away. An appropriate thought for the 4th of July. Happy Independence Day, everyone!

It seems incredible that we are starting our final week here in Swaziland – just as things are getting interesting! After a second meeting with the Ministry of Health, we have secured at least some level of funding for our family planning brochures from World Vision. We also developed a color version of the brochure and a poster version for clinics, just in case funding runs out for the brochures. We will be presenting these finalized materials before the Ministry on Monday

Also, our dipstick project has reached its (initial) conclusion! We have a finalized reading card ready to hit the clinic this week for testing! Also, we made edits on our liquid adherence charts and are going to be making a presentation about them (and the pill adherence charts) at ICAP this week.

The SOP is also coming along splendidly. I was a bit worried that we had no idea how to write an SOP and thus create something useless for the Ministry, but as it turns out, it is merely a starting point. Generally in Swaziland, people are fairly opinionated. But they need a starting point from which they can make changes and tailor documents to meet their needs. So, to aid in this process, we drafted an SOP of the process of job aid development. Hopefully, this will be a stepping stone to getting educational material in the country standardized.

Next, we will be meeting with World Vision, the Ministry of Health once again, and ICAP to get our materials printed and hopefully distributed – even if this does not end up happening until after we leave.

Over the weekend, we had the chance to go to Mkhaya Park. There, we had one very adventurous driver who took us right into the middle of a family of elephants. It was pretty intimidating to see them all up close and personal, especially this huge male who kept rubbing his foot and edging toward us. Here he is:

UNFPAFLASICAPCHAIWVM2MEGPAFSRPUHPU. Grammatically incorrect? Perhaps, but these letters have been the essence of our past few days (and will continue to be so, hopefully).

Our family planning brochure has successfully been translated and approved by the Ministry of Health! They want to be able to use it throughout the country at all PMTCT sites. The problem is that they are not going to be able to fund the printing of them. This is where all those letters come in.

We have been busy arranging meetings with several of these groups to gauge interest in the brochure. We really feel it would be beneficial to have this information disseminated throughout the country, as 40% of women of the age of having children are HIV positive.

We have also finalized a prototype version of the reading card to be used with the liquid adherence dipstick and should be testing it out on the expert clients soon! Job aids for this and the adherence chart we designed to accompany it are underway.

One new project that has come to our attention is through CHAI. The status of job aids in Swaziland is astounding. There is no regulatory body that maintains a list of what kinds of job aids are out there or how many of any given kind are in circulation. An effort is currently going on to create a database of all job aids in the country. We have been tasked with a branch of this project to create a Standard Operating Procedure for how to develop job aids in the country – quite a large task indeed. It is probably apparent by now how our work load has increased exponentially as the end of our trip approaches.

Last weekend, we crossed the border into South Africa to go to Kruger National Park. The park is about the shape and size of the country of Israel and has all sorts of wild life. In our time there, we only covered the southernmost quarter of the park, but we saw so many animals there in just two days, including what are known here as “The Big Five.” They are the lion, the leopard, the rhino, the elephant, and the buffalo. The park was mostly covered in low, brown grass, so we were able to see animals at greater distances (yay, winter!).

We also got stopped by the South African police multiple times to check our “boot” for, well, illegal booty, you might say. The whole trip was quite an adventure. Below is a picture of a friend we made along the way!

This weekend, I had one of the biggest adventures of my life. We went up to Malolotja Park and took the zip-lining canopy tour! It was quite an experience for sure, gliding above the trees while dangling from a cable.

Yesterday, in conjunction with a visit from Dr. Oden and Dr. Richards -Kortum, we attended five meetings, including ones with CHAI, ICAP, and EGPAF. They were all very excited to hear about both of our main projects, namely the liquid adherence dipstick and the family planning brochure that we have developed. This, of course, would be wonderful for us. We are still working on getting it translated into Siswati, however, many of the staff are experiencing difficulty finding the right wording for the brochure as it is rather technical.

One person who was invaluable to the translaition effort was the nurse manager. We asked her how she knew terminology that so many of the other native speakers did not seem to know, and her response was that she grew up in the rural areas, where she did not use any English to supplement her Siswati.

At our meeting with CHAI, we found out that we needed to contact a department in the Ministry of Health to look at the brochure, even during the translation stage. We’d heard about a similar department before, but found out then that it was one department called by two separate names – Swazi efficiency strikes again!

Also through the meetings, we were able to identify a few more areas of need. One was to develop an adherence chart for the liquid medications. This was much easier said than done. We have been working vigorously on it, but there are many variables that must be taken into consideration. Finally, today we also developed a job aid for the pill adherence chart so that even with the high turnover rate of nurses, pharmacists, and staff, new workers will be able to understand how the charts should be used.

That about sums it up for the past few days. We are really looking forward to three three busy weeks ahead of us!

When we first arrived in Swaziland, Dr. Stephanie, one of the BIPAI doctors, sent us a welcome email telling us to enjoy Swazi time. Since that time, we have had several experiences that got us well acquainted with this infamous Swazi time, but today, it afforded us a rather unique opportunity.

Yesterday, we finally had a meeting with ICAP, in which we clarified the issue of the missing adherence charts (a project started here last year). So today, we duly went over to a print shop in Mbabane where the order had been made. We arrived, confirmed that the proofs they had were of our charts, and placed an order for them to be printed.

While we were waiting for the driver to come pick us up, which has become a bit of a custom now, we decided to explore the complex a bit. The print shop was located in an industrial area of the city, part of a large, two-story building. We found an environmental building, a clothing store, and a dentist office!

Curious, I stepped inside to see what a Swazi dentist office would be like. It was a small office, with room for only one patient in the back. The front reception area was even tinier and was separated from the procedure room only by a glass door covered in thin lace. While the facilities were not spectacular in any way – they were fairly comparable to conditions found in the US – it was quite interesting to listen to the dentist talk about the standards she kept.

One major point of interest is that she took the same precautions with all patients as though they are all HIV positive. Often times, patients come to her office without knowing their status or even having any desire to be tested. As an oral healthcare provider, she is often able to identify co-morbidities that only affect those who are HIV positive and uses them as evidence to help convince patients to get tested. Patients need this sort of persuasion because in Swaziland, despite the prevalence of HIV, there is enormous stigma against it (as discussed in my previous post). Thus, many adults would rather not know their status and get treatment than to be looked upon as an untouchable.

The dentist gave personal examples of patients who she had seen things like angular cheilitis and hairy leukoplakia, which are only found in immunocomprimised patients. Being a dentist in Swaziland, she was in the unique position to see these patients in a seemingly unrelated setting and help them gain access to HIV care. What an amazing story! And the only reason I heard it was that things in Swaziland run on, well, Swazi time!

Our dipstick for liquid adherence project is starting to take shape! We have been working to finalize the measurements for the various bottle sizes of both Nevirapine and Kaletra. Nevirapine is a fairly inexpensive ARV given to infants who are born to HIV positive mothers to try and prevent mother to child transmission while Kaletra is given to those infants who were exposed to Nevirapine at birth, but still became HIV positive. Kaletra is expensive and difficult for infants to keep down due to the taste. As we were measuring, even the smell of the syrup was making my stomach queasy.

Since most of our projects deal with mother to child transmission of HIV, here are some facts to know. The normal rate of transmission from an HIV positive mother to baby is about 30% with no intervention. However, if the mother is on ART and the baby is protected during breastfeeding and delivery, that rate can drop to below 2%. In the US, HIV positive mothers would never be allowed to breastfeed their babies, as HIV can be transmitted through breast milk. In Swaziland, however, there is no such option, as infants who are not breastfed face malnutrition or even starvation.

While talking with some of the doctors here at the BIPAI clinic, we were able to get a small glimpse of what HIV positive kids face. Throughout the country, there is huge stigma against HIV. Yet for children, who are born with HIV and have no way of hiding, the stigma can turn to downright cruelty. Often times, families treat the kids (and think of them) as “poisoned children” and basically just wait for them to succumb to the virus. With 25% of the entire population HIV positive, this leaves a lot of children in this condition.

This is the sad reality in Swaziland. We can only hope that the small efforts we undertake to improve the quality of care here can have some small impact on the lives of these children.

On another note, we had the opportunity to climb Brackenhill this weekend. Here is a friend we picked up along the way:

On Saturday, we had the opportunity to go to RFM (the government hospital in Manzini) once again. Only this time, we were not there to observe the clinic or the hospital but rather to attend Teen Club, the support group here for HIV positive teens. This week’s lesson was about the mechanisms behind HIV in the body.

The kids arrived at the hospital around 9am and started playing games. At first, it was a bit of trial and error on my part, trying to figure out how each game was played. When I did finally catch on, I was on the lookout for those who are out but continue playing, which incidentally is not a good way to make friends. The kids I would call out would then line up in front of me, waiting for me to make an error. It was really enjoyable – in fact, I even got to teach the kids the action song, “Father Abraham!” It was wonderful to see the teens all so excited and willing to try anything, something not likely to happen with American teenagers.

After the opening session, the teens were broken into age groups: 10-12, 13-14, and 15+. I was with the 15-18 year olds but did not realize it at the time. Most of the kids looked to be anywhere from 8-10 years of age, as their growth had been stunted by HIV. We played a game called HIV Attacks which demonstrated how HIV infects the human body.

Most of the kids were in a circle around three others – one was the human immune system, one was HIV, and one was an ARV. We (the ones around the outside) had a ball which represented opportunistic infection which we threw at the little boy in the center who was the human. Generally, he would be able to dodge the ball easily. However, when HIV was present, she would immobilize him so he could no longer evade the opportunistic infection. But then, the new kid on the block, ARVs, would contain HIV, thus freeing up the immune system to once again avoid sickness!

Throughout the game, the kids answered questions about HIV and immunity. There were many kids who new exactly what HIV was, but there were some new teens. It was good to see them start participating by the end of Teen Club.

One thing I simply could not get over was the ease with which I could get smiles from the kids. Even though they were on daily medications and lived with a lethal virus in their bodies, these kids were so happy, hardworking, and friendly. It was something I hope I never forget.

Below is an image from Teen Club in Mbabane: