Reports from Swaziland

I am very excited that I will be leaving one unit of the bili-lights and the incubator at RFM. I am so glad that the devices are in great hands. The road wasn’t smooth; there was hesitation from a few pediatricians during the pivotal meeting. I understand their concern at the lack of a license; there is no safety net for them to fall back on if something happens. At the same time, I am extremely grateful for the understanding and backing of the SMO, Dr.Bichung and the head of pediatrics, Dr. Getahun, for acknowledging that the risks are minimal. Dr. Getahun even shared my private suspicion that the bili-lights might be safer and more efficient than what they are currently using, as I have checked both the wavelength and the intensity of the lights. Dr.Bichung, a medical researcher himself, empathized with the new technologies and their plight. Fear will always be associated with them, but for any technology to be successful, an institution has to pilot it. It is a balance of understanding the facts, acknowledging the risks and finally, trust. I am honored for the last one.

I had the opportunity to personally drop the bili-lights off at the neonatal ward with Dr.Getahun. It was the perfect chance for a demonstration and training session with the nurses. Although the device is not difficult to use, it is essential that it would be used correctly—to have the baby’s eyes covered at all times, to check the intensity of the light. I think most accidents happen as results of misconceptions or misunderstandings. The nurses’ excitement made me giddy with excitement as well. They liked that the device was portable and can be propped right on top of the incubator. It saves them the trouble of moving the baby from an incubator to an open bed underneath the florescent light; they must then carefully monitor the temperature of the room, which is more troublesome and costly than setting a temperature for an incubator. The concentrated area of irradiation was also a plus for them. The fluorescent lamp was too much a diffused source of light; I already saw cases where babies’ eye covers had slipped off and no one, not even the mothers, noticed. I did stress that the eyes must be covered at all times under the bili-lights, but the fact that the device mainly irradiates the baby’s truck and lower limb regions does minimize the risk of eye exposure. They were especially excited about the bili-meter; they passed it around and tested it on the fluorescent lamps. We found that the because the babies were placed so far underneath the lamps, the irradiance was low—at about two to five µW/cm²/nm—compared the standard of 15 µW/cm²/nm for mild cases of jaundice. Before I left, they were already discussing ways they could change. Like a mother, I watched with anticipation and wistfulness as the bili-lights got settled, with instructions written on the box on how to use it and the evaluation sheets placed next it for the nurses to fill when it is in use. The people at RFM are so friendly and open; I really hope we can continue to work with them in the future.

As for the incubator, I have to give thanks and gratitude for the workers and owners—the Irwins– of Woodmaster. As foreigners in Swaziland, Elizabeth and I really had no idea where to buy all the materials—wood, drills, screws; even if we did, we had limited forms of transportation for shipment and limited time to build the incubator. When I contacted Mr.Irwin at Woodmaster, he jumped into the project with enthusiasm. It is heart-warming to meet people who can see the potential of this project and is willing to lend a hand to achieve it. A big hand in this case. Woodmaster single-handedly build the incubator for us, ordering and assembling the wood, glass and wiring. Free of charge. I wished I had my camera with me when I saw the finished product; it was sturdy, beautiful, professional and much better than anything Z and I probably would have built. Mr. Irwin is definitely interested in collaborating with us on the project once it reaches the mass production phase and I do hope our paths will cross again.

In my previous entries, I had talked about MGH. Unfortunately, I was not able to convince them to pilot the bili-lights and the incubator. As it is right under the government’s nose, the hospital cannot accept any technology that does not have a stamp of approval from recognized agencies. I jumped all the hoops I could, but sometimes the effort just doesn’t equal the result. I meet with the doctors who directed me the SMO who lead me to the Biomedical Department where I individually meet with heads. I was to learn that at the very least, the devices needed to go through the South African Bureau of Standards. I appreciate the time everyone at MGH had taken to listen to me. They liked the projects, but as THE referral hospital in the country, they have much to lose from a new technology.

Leaving on a positive note, I was extremely glad and excited to have caught the deputy director, Dr. Mohammed Mahdi, of EGPAF in Swaziland three days before I leave. The foundation has a huge reach across Africa and a big reputation, at least in Swaziland. It funds about 70% of the equipment in maternity wards here as a part of their PMTCT sector. The meeting was wonderful. As a pediatrician himself, Dr. Mahdi understands the need for the cost-effective alternative technologies and is very interested in their potential. The foundation would be a powerful partner and I really can’t wait to see what the future will unfold.

Last week was a particularly busy week, with much to be done about the projects. I visited two government hospitals to assess the need for the bili-lights and searched for carpenter woodshops that might be interested in helping us build the incubators. One hospital that the doctors recommended to try was RFM (Raleigh Fitkin Memorial) located in Manzini, Swaziland’s industrial center and its biggest city. Baylor has a small satellite “clinic” –a room—in the hospital where the PAC doctors could see the HIV patients who would otherwise had to travel far to Mbabane for appointments. Dr.Erin is the main physician in charge of the clinic, so I was fortunate to catch a ride with her.

RFM is much nicer than MGH. The structure of RFM reminds me much of a Spanish villa with its palm trees and arches. It takes a great memory to maneuver through the maze of winding walkways through arches and rose bushes. I particularly liked that the design of the hospital allowed patients to wait in open-air hallways encircling a court yard, thus lessening the impact of body odor on the nose and possibilities of air-transmittable diseases. The services offered are the same as MGH, although I think RFM might be better-off than MGH.

RFM is definitely a different type of hospital than MGH; even though RFM is technically a government hospital, it is also funded by the huge Christian group Nazarene in Swaziland. Nazarene, from what I understand, is sect of Christianity started by Swaziland’s first white settlers. The Nazarene pastors built churches, schools and villages and thus are deeply integrated into the society. The state’s official religion, Christianity, is serious here. Most people go to churches on Sunday (four hours) and almost no stores aside from grocery and movie rental stores–which we are grateful of—are opened on that day.

I only had a brief meeting with the head SMO on my first day to introduce my project—a literal five minute introduction before he had to give a tour to prospective donors. Despite the hurried timing and the meeting being my first with someone so important, his affable air—with his scholarly glasses and benign smile—eased my nervousness. He was wonderfully interested in the bili-lights and the incubator, even offering to discuss the details of cost. Oh course we were not selling them (no yet) but it was great hear that there enough interest for monetary involvement. He offered me a chance to formally present the idea on that Thursday at the pediatric department meeting.

I also met with the head of pediatrics, Dr.Getshu, that day to give a sort of “heads-up” about the presentation, to test out the waters and gain his voice of support, if needed on Thursday. He was extremely enthusiastic about the cost of the incubator and the bili-lights, which are thousands of rand below what they are paying now. For them, an incubator costs about thirty thousand rand, which may not be a lot if in dollars but is a substantial amount considering the standard of living here. He is a very scientific man—the only person who delved into questions about the electronics—who liked to share his enthusiasm about the new devices. He actually took me to the neonatal ward and demonstrated it to the nurses, which also gave me an opportunity to tour around the unit. I had learned earlier from Erin during the ride that the hospital is currently trying to improve their infant mortality rate so the beefing up of their neonatal equipment was expected. The hospital has about five incubators, but Dr.Getshu admitted that the high-tech units are not permanent solutions because they have no means of fixing the incubators once they malfunction in a few years. In terms of jaundice treatment, RFM uses two units of the portable blue-lights that can be rolled from crib to crib and one interesting innovation. It resembles in shape and mass to a chemistry fume hood. The neonate can be placed on the table and directly above him is a row of the long tubed, blue fluorescent light spaced lengthwise. It is the most economically suited device for the hospital; the florescent light can be replaced for a few hundred rand every year (every year!). Unfortunately it is not feasible to have more than one of this machine because of the sheer bulk that not only takes up 1/3 of the room but also prevents it from being portable. I think I was very fortunate with the timing; RFM, despite being relatively well-funded, is still facing the same healthcare issues such as high infant mortality as the rest of the country. The bili-lights and the incubator would be a great part of a cost-effective step to improving care and conserving resources.

While the advantages to the bili-lights and incubator were obvious, I knew that convincing the hospitals to test the devices might not be easy. I am essentially asking the hospital to use two devices that have not been approved by any recognized safety agencies. Even though both devices are undergoing CE certification, the current lack of safety backing by trusted organizations is the Achilles’’ heel of the project, so it was understandable that at the Thursday’s meeting with RFM pediatricians, there was hesitation about the devices. The doctors were all very fascinated with the technologies’ simplicity and novelty, but the missing certification stamp hung like a dark cloud on their conscious and also made the confirmation process with the government difficult. I found it interesting that our safety discussion was almost completely centered on the bili-lights, whose safety depends on a background knowledge of scientific and physiological principles such as irradiance, wavelength and bilirubin breakdown that they were not entirely familiar with. It is a bit ironic that I have probably done and set more safety tests and regulations on the bili-lights than they have on their currently used devices. I doubt they have measured the wavelength of the florescent bulbs to see if it is near the optimal range for bilirubin breakdown. I fear they are also using the lights dangerously. They have neither heard of the standards on irradiance nor do they have the equipment to measure it. I have seen phototherapy lights being placed very close to the infants, but without a bili-meter, there is no way of ensuring the baby is not experiencing over-exposure of the radiation. Overall the discussion was much like running my head first against the wall because the baseline was: I do not have an official safety approval. I was glad I had the SMO and Dr. Getshun’s understanding and support. They see the potential of the devices for not only the hospital but for the rest of the country in terms of improving primary neonatal health care. They realize that in order to obtain certification, the devices need to be first pioneered in a few hospitals. In return for their trust, I compiled a manual of all the tests and scientific reasoning involved in the design and operation of the bili-lights for their review. I am meeting them this week to have their final opinions on the project.

I also meet with the SMO from MGH on Friday. I was actually initially warned by Stephanie that this meeting might be difficult because Baylor does not have a close relationship with the current SMO. I had a taste of the infamous “no urgency” syndrome prevalent here and in the various areas of the developing world I have traveled to such as in Mexico and China. We made the appointment for 8 ‘o clock, but Stephanie and I had to wait outside for 30 minutes, partially because the SMO didn’t arrive until 8:15 and then failed to call us in after she saw us because she had to peruse the daily newspaper for another 15 minutes. Time just has a different meaning here. Despite the inauspicious start, the meeting progressed in much the same tone and format as the one with RFM with safety of the bili-lights being of most concern. Her attitude was cool, but I hope the manual and Dr.Akingba’s –head pediatrician–warm support will be enough. I am scheduled to meet with her this week to see if we can make any progress.

Swaziland is a much richer nation than Lesotho and Malawi, two countries that are using the projects. The government provides enough funding to the hospitals to buy a few units of necessary medical equipments. The doctors thus can afford more doubt and uneasiness on unconventional technologies. However, that does not eliminate the need for more cost-effective and resource-appropriate devices. I am learning that it is one thing to introduce the project and another for the projects to be used and used correctly.

On another note, Dr. Michelle Adler, who also works at the Baylor Clinic, has introduced me to EGPAF which may be a great partner for the projects if the incubator and the bili-lights reach the mass-distribution stage. The acronym stands for the Elizabeth Glaser Pediatric AIDS Foundation that is dedicated to fighting pediatric AIDS through funding research, launching global health programs and advocating for children’s health. The Foundation works in many African countries including Rwanda, Mozambique, Uganda, Tanzania and Zimbabwe and countries BTB has contacts with such as Swaziland, Lesotho and Malawi. Michelle thinks it may be possible to gain its support as EGPAF sometimes fund equipment for maternity wards as part of their PMTCT (prevention of mother to child transmission) support. I have contacted the coordinator for the Swaziland division and I hope I can have a chance to meet with him before I leave (in a week’s time).

Coming to Swaziland, a main goal for Elizabeth and I is to implement our projects. Our other job is to help around the clinic, picking up secondary projects that we can do. One of our main side-project that we just finished this past weekend was the teen club. Pioneered by the Baylor clinic in Botswana, the club provides a great venue for HIV positive adolescents to live positively and to become not only educated about their condition but also empowered leaders who can direct their community to a new HIV movement. The teen club in Swaziland meets once a month; about a hundred kids arrive early in the morning, some at the door as early as 7’o clock. In addition to the sessions that begin late in the morning, the teens have a chance to see the doctors and have their pill refills so that they do not have to miss school. Swaziland has a strict discipline about school attendance. I meet a mother whose boy received beatings from the teacher for being late despite his having the PAC doctor’s legitimate note excusing the boy. The boy’s appointment time was changed to the teen club.

Elizabeth and I created a curriculum that included topics from sexual development and reproduction to contraceptives and positive prevention. We were lucky we could compile a lot of activities that would reinforce our messages; we drew upon the advice of past BTB interns in Lesotho, the head of the Botswana teen club and one of Elizabeth’s friends who had worked on family planning extensively. Even though we only had time to cover sexual development, I thoroughly enjoyed my time with the teens and I feel that it was an amazing success. The social worker who leads the teen club will continue the rest our curriculum in the future.

It was intimidating to watch about 60 kids slowly filling the classroom, but I knew it was going to be a good day when they remembered my name after being introduced once—I can’t even achieve that if the name wasn’t mine. The teens were a lively bunch whose energy and attentiveness to our activities took them beyond our expectations from the very beginning. Our first activity was a sort of icebreaker to crack the sex taboo by asking groups of teens to write down synonyms/slang words for various sensitive sexual terms we gave them. It was wonderful to see the kids huddling together, giggling over words such as “butt” or “sex”, but also whispering about what to write. I stumbled a bit when a girl approached me and asked what an orgasm was; I like to think that I gave an honest answer. I think the fun atmosphere the activity established really allowed the teens to become more involved in the lessons. They were actively participating in the discussion afterwards, sharing some intense slang from the expression of our translator and deciding collaboratively as a group which words were appropriate to use in the classroom. Of the many outrageous slangs they shared, I learned that sex can be referred to as “cutting the cake”.

As we progressed through the lecture, it seemed that the teens were familiar with the physical changes relating to puberty, but they had misconstrued notions about the anatomy and physiology of sexual development. When we asked them to draw the male and female reproductive organs without using references, they were unfortunately far off target. For female, they drew a baby inside a woman and for male, the penis. I was very glad we covered the anatomy because it really clarified and illustrated some of the background knowledge they needed to understand reproduction. We discussed extensively the menstrual cycle; there was a prevalent a belief in the classroom that the bleeding is from the egg exploding. Questions came from around the room, but I was surprised to notice that the guys predominately asked the questions about the female reproductive system. The girls may possibly be shy, but they did actively participate in the activities.

Overall, I was very impressed that all the kids were attentive to the lecture, not only to the games but to the slides. I felt that the teen club really acts as an open outlet for the kids to embrace their status, confront their questions and uncertainties and most of all, to be themselves. They did seem afraid to share their opinions or to ask questions and even sought the doctors’ opinion on the political issue of HIV branding. Apparently, a man running for office in the Ministry of Health thinks that he can gain popularity by being open about the HIV issue. For a man who hasn’t himself been tested, he proposes that all HIV positive patients should have a HIV brand on their gluteal region so that HIV status can be openly known between partners.

Teen clubs is one of the best experiences I have had in Swaziland. With these kids’ enthusiasm, the HIV situation in Swaziland may not be so dark in the near future.

On a small side note, I also enjoy the reading time Elizabeth and I had with the kids in the waiting area. Each of us would have a circle of very cute, overly eager, slobbering kids who we would read to while they fight for position in our lap. The kids sometimes have to wait quite awhile for their appointments, so I am very glad that we can at least entertain them for an hour each day.

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.”

Unless a person has personally visited a government hospital or one of the rural clinics, the HIV statistics about Swaziland do no justice to cycle of destructive impacts the disease has rack to the people. Official HIV prevalence of Swaziland is reported to be around 40% but most suspect that actual percentage is around 50%. 80% of inpatients to government hospitals have HIV.

Driving up to the Mbabane Government Hospital (MGH), located in the central government district, I saw an imposing muti-story, red-brick building next to the hospital’s parking lot and thought to myself this must be the hospital. When we walked the other way, into a dimly light hallway of what I can only describe as a delipataded jailhouse, I was stunned that this was the government’s hospital, the premier public hospital in this kingdom. I can’t believe it of myself now, but at that moment, I asked out loud “Is this the government hospital?”

Big chunks of paint were peeling everywhere the eyes can see. What much could be seen was mostly though natural light passing through often web-cracked windows. Doors leading to wards or conference rooms were reinforced with bar gates. In the pediatric ward, bugs, roaches were easy to spot as they moved without fear. It is not as worse as a hospital can get, especially after reading the Lesotho interns’ experiences, but for Swaziland, a country considered to be one of the richer nations in Africa, where there are no outright beggars, where people dressed so well, where the MGH is located in the center of a rich government district, I expected more. I expected that the Swazi citizens would demand more from their government. It was really shocking to see the contrast between the condition of the hospital and the government building across the street. It was an overt sign that the government’s focus is not where it should be.

The facilities inside the hospital didn’t get much better than the hospital’s appearance. I am glad that it is equipped with basic diagnostics such as ultrasound, CT and x-ray machines and with a decent lab. The hospital might more or less meet the demands of a HIV-free population in a developing country, but the high prevalence rate of HIV opens so many doors to common and unusual—all serious—diseases ranging from cancer to simple opportunistic infections that it becomes very hard for doctors to diagnose and treat, especially in a resource-limited sitting. I won’t detail all the cases, but to state simply, I saw doctors who could not diagnose children because of the lack of laboratory capacity and patients with serious forms of cancers like osteosarcoma who cannot get treatment here because there is no oncology center in the country.  Almost all the cases we toured—nine out of eleven—were HIV-related. We weren’t specifically shown HIV cases; we followed doctors on their morning rounds and discovered that almost all cases were linked to HIV. The prevalence rate, when you see it in face after face, on bed after bed, is shocking.

What was perhaps most heart-wrenching to see was that the kids just seemed to be hit from all sides as soon as they are born: malnutrition, HIV, respiratory infections. Almost every kid we saw had all three of these: three inseparable sisters that pull the children into cycles of unrelenting illness. The infants get HIV either from their mother or through breastfeeding. They almost immediately become malnourished due to the socioeconomic conditions in the country. Both then make them easy victims of ubiquitous respiratory infections like TB and pneumonia. If a baby is lucky enough to avoid TB or pneumonia but is admitted to the hospital, he will get either one during his stay because all the children are kept in the same room. Life is unbelievably harsh to a baby here.

On top of everything, I learned that there is no medical school in the country. None. A person has to go to South Africa to receive training and if Swaziland is lucky, he might come back. Of the four pediatricians I meet (the only four in the hospital), three came from another country. The hospital is attempting to try task-shifting. When the pediatricians make their rounds, a group of nursing students follow each doctor much like medical students or first-year residents. However, no matter how the people try to compensate for a government’s inattention, it is clear that the government needs a firmer commitment to the health of its people, especially when it is in such a dire situation. At times, I feel that the people must demand it, must want it from their leaders. More Swazi citizens must show their own commitment to health and more men voluntarily need to be tested and treated.

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.

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.

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. 

Finally. Finally I am at Mbabane, Swaziland. After spending a day here, my life in America and what I have done in the recent past—my trip here, my week of little sleep  (in order to finish my project)—seem far away and long ago. Swaziland is real; America, a dream. I think it is appropriate to start from the beginning, but I must warn whoever reading this that I am writing a blog for the first time.

I am on a ten-week internship in Africa. I will be spending 5 weeks in Mbabane, Swaziland to work in the BIPAI Center of Excellence and another 5 weeks at St.Gabriel’s Hospital in Malawi. My travel companion, Elizabeth or better known as Z, and I have brought with us three projects that we hope to introduce, implement, analyze and improve upon during our stay. One is what I have been working on in the past year: a neonatal jaundice phototherapy device, or for short, the bili-lights. The nickname fits because the device uses blue 470nm light from LEDs to breakdown the excess buildup of bilirubin in newborns’ blood. The bilirubin–a yellow component of hemoglobin decomposition–is the cause of the yellowing of skin in infants, a condition known as jaundice.  If this fairly common condition is left untreated, kids will develop hearing loss and mental disabilities. I am hoping that the two 60-dollar models (compared to the current devices averaging over a few thousands a piece) I brought to Swaziland will find a need and true use here. The other two projects are the Diagnostic Lab-in-a-Backpack and its spin-off, the Community Health Worker Screening Kit (CHW kit). Both use backpacks to organize and store medical equipments traveling doctors need on their outreach trips to easily assess an individual’s health. The former provides doctors with helpful diagnostic tools–such as urine dipstick strips, a microscope and centrifuge—that are backed up by a solar-charged battery system. The latter is a backpack to support community health workers in basic checkup and assessment of local primary health.

The bili-lights, compounded by the fact that we have no access to the internet at our guesthouse, are the reason why I am blogging this late. Last week, before I left on Saturday, I made about twenty bili-lights that will travel with a few summer interns and myself to be tested across the Atlantic Ocean from Haiti to Malawi. I have gotten at most four hours of sleep these past few days, including the plane ride here, so I can’t wait to catch up on some solid rest in Mbabane. Despite my current state of sleepiness and the ominous pouring Houston rain on the day we left, our trip so far has been blissfully smooth and fun. We enjoyed a wonderful 12-hour layover in London that gave us ample time to take an impromptu walk around the famous city. Armed with only a map, our group of eight interns to Africa (we were together until South Africa) rode the subway that took us from Heathrow to the heart of London. Westminster Abbey, Buckingham Palace and the Parliament stunned me with their intricate beauty and the heavy weight of history filled with blood, wars, and glory. However, it is the little things I noticed that fascinated me. There is a distinctive modern air of freedom in the city, seen immediately in its people, in their edgier, if not sometimes downright outrageous, fashion.  Within a few minutes of strolling down the street, we saw a lady biking in her bra—definitely confirmed by the lacy and intimate design. Yet, a deep sense of classic activity untainted by the droll of television or the smog of cars was infused to the city. Bikes were a common type of transportation but so were roller skates, as I witnessed for the first time. Lush green parks popped up randomly in between blocks with couples and families settling busily in the shade, reading newspapers or sharing food beside the type of classic picnic baskets I have only seen in movies. (Picnic baskets rather than coolers!)

What made the plane trip truly light on my heart was that our luggage arrived safely with us to each transfer point; i.e. we landed in Swaziland with all our bags. (Luggage is renowned to be lost during inter-African airline transfers.) My luggage bag did have a suspicious tear at the bottom when I collected it at South Africa airport, but none of my things were lost. In fact, I was hugely surprised that we did not have to pay overweight charges on the 61 pounds bili-lights-and-CHW-screening-kit suitcase on South African Airline (SAA) flight to Swaziland. (We did for Continental.) According to SAA website, they should have charged 50 dollars per kg over, which meant that we would have paid around $300. I guess the reason our luggage did not get lost was that we actually saw the workers load each checked-in bag onto the plane. I think Z and I both held our breath with each lift of a bag as we hoped it was ours. We luckily had the right draw because whereas our suitcases were loaded, we saw five other bags being left on the docking station. What a small plane it was!  My first time riding a propeller plane no less. Z and I actually sat next to the spinning propellers and shared a look of raised eyebrows. It turned out to be a noisy but smooth flight.

We landed in a small town near Mazini, the industrial center of Swaziland when the purple of twilight was given away to night. We were very glad an experienced taxi driver was sent to pick us up because we encountered a minor hiccup right away. The officials asked to search our black boxes that contained our projects before we checked out. Despite the note Z showed them declaring that the cases are free gifts to Baylor, the officials were reluctant to let us pass, relentlessly asking us for a complete list of the items in both cases. The taxi driver came to our rescue. After a few minutes of Siswati being exchanged, we came out with everything. On our 40 min car trip to Mbabane, we were presented with a beautiful, sparkling image of night view Swaziland. We were surrounded by towering mountains darker than the sky, illuminated only by the sparse twinkling of lighting from houses perched in darkness. I was surprised that there were still many people–many women in fact– walking on the side of the streets, carrying plastic bags of groceries. There were even small fruit stands still standing. I guess only foreigners get mugged.  On the roads, especially on the highway, people were waving their hands to hail rides or the small public white buses. We arrived at Veiki’s guesthouse which is just a seven minutes walk down the street, up a hill from Baylor clinic. We each have our own room and share a bathroom. I feel very safe at the place; konwing that there is friendly guardsman and a serving maid situated at the front of the house each night. We immediately readied for bed because Dr. Stephanie Marton was picking us up at 7:30 in the morning on the next day.