Reports from Swaziland

This week marked the leaving of one more of the BIPAI doctors, so the clinic is currently only staffed by only three PAC doctors (PAC stands for the Pediatric AIDS Corps). BIPAI Swaziland COE was originally started to be staffed by 10 doctors, so things have been pretty busy around here.

During this crazy week, we were able to develop a brochure regarding family planning services offered at the clinic. Family planning is very important here because families tend to be very large (I met a boy here who has 8 brothers and sisters) and with 25% of the adult population HIV positive, family planning is essential to containing the spread of HIV. Family planning services include the pill as well as monthly or bimonthly injections, a five-year implant, and a ten-year intrauterine device. We submitted our draft to the family planning nurse, who is from Kenya, so she can edit it for accuracy. We hope to be able to distribute these in the waiting rooms so that women can go into their appointments well-informed and with specific questions in mind, thus allowing the doctors to be able to spend less time teaching patients about it and allowing them to see more patients in their extremely limited time.

We also had a chance to meet with the Swaziland director of the Clinton Health Access Initiative and discussed the country-wide roll out of the DoseRight dosing clips. The clips arrived in country last Monday, and very soon, the distribution will be underway! Demonstrations, monitoring methods, and ordering guides will need to be developed, and this is where we will be coming in.

Today, we also had a chance to climb up Sibebe Rock, the world’s largest open granite peak (pictured below). While it was a struggle getting up to the top, the view was absolutely breathtaking. Feeling very accomplished, we descended the rock looking forward to getting started on new projects!

The latter half of this week largely focused on getting a translator for the dosing clip study. After getting a protocol finalized, we took it to Macmillian Publishing Company in Masapha for translation by an official translator. I had never been to a publishing company, so getting to see the warehouse a pretty fun experience. As for the translator himself, he were very efficient in his translations- he called the next morning and said that it was ready!

I also shadowed Dr. Kelly, who is a visiting scholar here, for a while. Apart from seeing patients, she showed me how the labs were read. One interesting point that came up was how there was some inefficiency getting the lab results interpreted and into the patients charts. Since the COE has computerized  patient information and paper data, the lab reports (which are computerized initially) are printed, given to the doctors who interprets them and enters the abnormal lab reports in the computer system, and then the normal lab reports are given to someone else to enter in the computer. It would be much more efficient if the lab reports could be directly filed electronically for the patient, rather than having the middle paper step.

Following the TB nurse, we were able to observe one really interesting fact regarding the health care system here: because there are so few doctors, nurses many times take the role of the doctor for the simple patient cases. They are able to prescribe antibiotics for any of the patients complaints and are able to give refills of ARTs. This is a huge difference from health care in the US!

As the first full week draws to a close, we began thinking about possible projects to improve some aspects of the health care here. One of the most apparent concerns which significantly effects health in Swaziland is that HIV is killing the middle-aged people, leaving many HIV+ children in the care of the older, grandparent generation. These problems are all worsened by the fact that mothers normally have many children- sometimes up to 10- who are HIV+. Of course, family planning can help alleviate the problem, and the COE offers multiple family planning options. Thus, one project idea that we had was to educate the patients in the waiting room of their options for family planning by having readily available one-page brochures in Siswati on the topic. We talked to the family planning nurse, Ann, and she showed us the various contraception methods that the clinic has to offer. We think that if the patients are informed of the methods while waiting in the waiting room, they can think about it and ask their doctor when they see them. Quite an efficient use of time for them, indeed!

This weekend, we had the great opportunity to participate in Mbabane’s Teen Club which takes place here at the Baylor Center of Excellence (COE). Teen Club happens every Saturday in different places in Swaziland, and kids ages 10-18, most who are HIV +, come together to play and learn about health related topics. They are divided up into age groups 10-12, 13-15, and 16-18 and do age appropriate activities. I hung out with the 13-15 year olds, and our activities were related to male and female anatomy and body changes during the adolescent years. They had a short Q&A session, which included a lot of singing, but my favorite part was at the very end when they all sang “The World’s Greatest” by R. Kelly. Everyone sang with so much enthusiasm and energy- it was really touching and inspiring.

For fun, we also explored the town of Mbabane. We got a chance to visit the fruit and vegetable market and look at some of the shopping areas in The Mall and The Plaza. Mbabane is actually surprisingly westernized! Also, there are many billboards that are geared at reminding people of the HIV problem in the country and reminding them to take precautions so stop the spread of it.

At the clinic, we got a chance to shadow the adherence and phlebotomy expert clients and the pharmacist. While observing the adherence department, we found that adherence charts are no longer used here because they have an excellent computerized system for each patient that calculates the adherence if told the number of days since the last visit, the dose, the number of pills given, and the number of pills remaining. At Mbabane, the adherence has to be from 95-105% for it to be considered good adherence, and if patients are not being adherent they were send to a social worker. They unfortunately didn’t do any liquid ARV adherence, but they said that they just measure the remaining volume of liquid using a syringe or measuring cup and calculate the adherence the same way. However, we need to find out if all outreach clinics take as much care in measuring the liquid ARV volume. In the phlebotomy lab, we watched blood draws, and Pepsi, the phlebotomist, informed us of the blood tests that are run at the COE. At this clinic, they are very careful with blood draws; for instance, she would bend and incinerate the sharps for disposal after use. Finally, we visited the pharmacy. Since patient records are all computerized here, filling prescriptions is quite organized. The one thing I learned while in the pharmacy though is that even if some practices do not conform to what we deem as correct in the US, they are done here with a good reason. For example, they have prepackaged sets of tablets for easy access, but they don’t label the cabinets these tablets are in so that only the pharmacists know which drug is which and others cannot walk in and take the drugs they need. It may seem strange initially for us, as we are so used to everything being labeled, but this system works well for their situation!

On Tuesday, Dr. Eric took us to Baylor’s satellite clinic at Manzini’s RFM, Raleigh Fitkin Memorial Hospital. Since both of Baylor’s satellite clinics are attached to government hospitals, they are exclusively pediatric clinics, since the parents can go right next door to the adult AIDS clinic. The RFM clinic is much smaller than the COE, with less staff and fewer patients. A sad but interesting fact was that most of the tiny babies were brought into the clinic by their grandparents, since many times their parents would have already died from AIDS. It was also interesting to see that all of the records there were kept on paper, whereas the records at the COE are kept on paper and computer. Since there were few computers at the RFM clinic, adherence was calculated by hand using a few simple formulas. Perhaps the use of adherence charts here would be helpful. We also got a chance to tour RFM government hospital. It was quite a large open air hospital that was very crowded. Our visit to the children’s ward was the saddest because there were so many children in unhygienic conditions receiving little medical care. However, remembering the happiness of the children in Teen Club gave me hope that someday these children too would be healthy enough to run and play with other children!

Teen Club                                                                            Stop the Spread of HIV billboard

We have officially been in the country for one week and have spent most of our time observing the clinic and working on finding a licensed translator for the dosing clip study. While this may seem like a common enough request, it has been quite an ordeal here. The only one we were able to locate was through UNICEF and lives in Matsapha, the city where we first landed.

Yesterday, Dr. Eric, one of the Baylor doctors, took us to a Baylor satellite clinic in Manzini. The clinic was much smaller than the one in Mbabane, seeing only about 50 patients a day. It was located right next to the government hospital, thus allowing it to serve only pediatric HIV patient, unlike the Mbabane COE which also saw adults and non-HIV-related illnesses.

One thing I noticed at this site was the much higher number of Gogo’s (grandmothers) who brought their children to the clinic. In Mbabane, there were many mother mothers and fathers coming in with their children. Manzini also had a disproportionate number of very young babies coming in. Most were right around one year old and HIV positive – for me, it was really difficult to watch. The Gogo’s tied the babies onto their backs with large towels or small sheets. Gogo’s are much more dedicated to keeping kids strictly on their regimens than parents because they are part of the older generation who remembers what Swaziland was like before HIV took the country with devastating force. Many have lost their own children and seen the change in the country that the epidemic has brought and thus want to do all they can to protect their grandchildren from it.

One of the patients was a little boy who came in with both of his grandparents – he, too, had lost both parents to HIV. Around nine years old, he had already failed the first line ARVs. His virus had thus gotten stronger, causing him to have to stroke and leaving him unable to even walk from the waiting room to the exam room – his grandfather had to pick him up to bring him into the room. He had to be prescribed second line ARVs. As HIV becomes an older disease in Swaziland, many more people will end up failing first line and even second line ARVs.

At the end of the day, we went to see the government hospital right next door, and afterwards observed a patient visit for a pregnant woman. During this visit, Dr. Eric told us that women here have very little power in their relationships. Often, the man of the house decides unilaterally how many children they will have, even if her health is being affected. Thus, family planning is a big issue here. We may end up pursuing a project related to that area.

For now, our mission is clear: find that translator!

After 2 overnight flights, passing through London and Johannesburg, Caren and I finally made it Manzini, Swaziland on Wednesday! We were picked up at Mashapa International Airport and taken to the Baylor Center of Excellence Clinic in Mbabane. There, we were briefly introduced to Treasure and Dr. Eric Dziuban. We actually made it there just in time for a farewell party for two of the doctors in the clinic and got a chance to see all the BIPAI staff there. We were quite exhausted that day and crashed early!

The next day was our orientation day. After running basic errands in to morning, such as grocery shopping, we got a chance to sit down and read a bit of the HIV Curriculum that Baylor has made for the medical providers here. Then, Dr. Eric gave us a brief orientation regarding Swaziland, its people and their culture, and the local thoughts about HIV here. Finally, we had a chance to discuss our projects for this internship! Dr. Eric said that there is a need for improvement in liquid ARV dosing adherence testing. He said that next week, we could talk to the adherence expert clients in this Baylor clinic as well as those at the satellite RFM Baylor clinic, and investigate what their current strategy is for assessing liquid ARV adherence. Regarding the ARV pill adherence, Dr. Eric said that the current system is working pretty well, but we will be following up more on that next week too.

On Friday, after taking the appropriate NIH training module for research with human participants, I started working on finding an official licensed English to Siswati translator to translate documents for the dosing clip study. For those of you who might have not heard about dosing clips, in a nutshell, they are small clips that are designed to be inserted in dosing syringes such that the caregiver can easily uptake the correct amount of liquid medication to give the patient. A study to assess the efficiency of these clips has been conducted in Houston, and our aim now is to conduct a similar study here in Swaziland. Of the 6 patient clients in the clinic who commonly translate for the doctors here, unfortunately none of them are officially licensed. However, I did get a chance to talk to the nurse manager to help find an official translator in Mbanane.

Well, that about wraps it up for this short week!

I left the show-me state two days ago, and having flown through three continents, during which time we got to see a bit of London, we finally landed at a tiny airport (having no gates) in Manzini, Swaziland. During the short flight from Johannesburg, I was taken aback by the beauty of the barren land below me – miles and miles of rolling, grassless hills with different sized patches of trees hung like ornaments on the dusty terrain. Our final destination: the Baylor International Pediatric AIDS Initiative Center of Excellence located in the capital city of Mbabane. We had landed around the time school had let out, and saw many small children bundled up in the Southern African winter, carrying backpacks and running down (and sometimes across) the streets. There were several small, one-room houses, open-air fruit stands, clotheslines swathed in multitudes of colorful clothing, and bright red dirt roads.

When we finally reached the clinic, I was greeted by a sturdy two-story building with a nice waiting room, several well-equipped examination rooms, and laboratory facilities – and our room just 30 seconds away: our home for the next two months. This trip to Swaziland is a part of the Global Health Technologies program at Rice University in which students learn about the status of healthcare across the globe, specifically in developing countries, and work in groups to develop simple devices that can be used in different locations to improve the ease or quality of delivered healthcare.

We look forward to sharing our experiences here is Swaziland!

I’m currently working on a longer blog post to make up for lost time, but I just wanted to give you a quick update- Ben and I are indeed still surviving here in Swaziland, no need to worry! I apologize for not having updated the blog in so long, but I haven’t even figured out yet how the past few weeks have flown by. While wrapping up our internship, we’ve spent our time getting design feedback in places from the rural Hlatikulu BIPAI clinic to the mobile outreach van of Gone Rural BoMake, and more lesiurely taking in the views from the top of Swaziland’s Sibebe Rock to the guided night safari of Kruger National Park. Saying that our time here has not been filled with a variety of experiences would be completely inaccurate… I’m still enjoying it as much as ever, and I can’t believe our time is coming to a close so soon!

Primitive.

 That was the word Sister Diane used to describe the mud huts, dirt roads, and general culture in the Lubombo region. She stated it matter-of-factly and without any hints of condescension. At first, you would imagine that such a word would be too harsh to describe any community in the modern world. After all, technology and society has progressed enormously during the past century. But all of these advancements have occurred in developed countries and the wave of progress seems to have skipped over areas such as southern Swaziland.

 In addition to living in mud huts ( a picture of one of the nicer homesteads we visited is below), most people there are also living without running water, electricity, or a steady source of income. The only local industry in the region comes from harvesting sugar cane, but until the dam was constructed recently, farmers were only able to grow sugar cane during the summer months. These challenges, though, have not kept farmers in other areas from progressing. For the past 15 years, however, the Lebombo region has also been crippled by the a massive drought as well as the HIV-epidemic.  The epidemic devastated the region, wiping away an entire generation and crippling a society that depends on the productivity of its young adults.

Last week, Lauren and I visited the Cabrini clinic in St. Phillips (the rural community). Unlike the clinics in Mbabane and Manzini, the Cabrini clinic actually goes out in to the rural community to provide outreach care. The nurses who go to each homestead are tasked with distributing medications (mainly anti-retroviral treatments), distributing food, providing counseling, and providing immunizations. Expert clients who go on outreach missions are given a trickier task; they are asked to track down patients who have stopped coming to the clinic or have defaulted and encourage these patients to continue their medications. These expert clients also perform phlebotomy (blood draws) to check CD4 counts and liver function. I was fortunate enough to join both the nurse and the expert client. Considering how comfortable I have been living in Mbabane, it was certainly an eye opening experience to go out into the community and see the widespread travesty.

 The St. Phillips clinic, like most other African clinics, is mostly staffed by nurses and expert clients (specially trained civilians). Though they have recently received funding and equipment from international organizations, they are not as well-resourced as other clinics we have visited. We were therefore able to use our adherence charts and, for the first time, demonstrate how to use the salad spinner centrifuge. We also left our transilluminators with the clinic to use, and I was able to draw a rough sketch of a phlebotomy kit for our transport system. We were definitely encouraged by how receptive the clinic staff was to our technologies. I feel that it is in clinics like St. Phillips that our technologies can have the most immediate impact.

 In addition to the feedback that we received for our technologies, I felt that being able to see the impoverished conditions in which some Swazis are living was an invaluable experience. Until last week, mud huts were only a piece of my mother’s fictitious impression of where I was staying rather than an actual part of my African experience. It also made me realize that there are so many other barriers to delivering healthcare than simply having access. Even though there is a well-stocked clinic that has become integrated into the community and that has programs to make receiving healthcare as seamless as possible, there are still major cultural and societal stigmas that prevent people in St. Phillips from accepting treatment.

 But that is a discussion for another entry. For now, happy Independence Day and I hope that you are able to enjoy the fireworks back home.  

This week, Ben and I spent three days at the Cabrini Clinic, a small facility situated on St. Philip’s Mission in the eastern part of Swaziland. On the drive across the country (about an hour and a half away), I was quickly made aware of the fact that life in Swaziland changes drastically outside of the main cities of Mbabane and Manzini. We’ve spent most of our time here so far on paved roads, with reliable running water and electricity in houses and facilities, but my perspective was greatly expanded while at St. Philip’s. My eyes were opened to thatched roofs and makeshift shelters, with access to water for many families a very long trek away. The clinic itself was fortunate to have water and electricity, but the nuances of well-staffed and equipped facilities like we have at Baylor were not to be seen. Some clinics like this are fortunate enough to have a doctor visit once every one or two weeks, but aren’t able to have access as often as they would like or need. Things like unreliable transportation systems prevent many patients from coming to seek treatment, and thus many lives are regrettably damaged.

On the first morning, after the daily staff meeting and check-in, I went out “tracking,” which consisted of driving through the most rural homesteads and communities I’ve seen in order to find patients who had defaulted on medications, missed appointments, or been otherwise unresponsive to their HIV counseling and treatment. I had no idea this practice existed, as it is part of a recent effort to strengthening community linkages, but I am beyond impressed by the dedication to patients’ wellbeing that it demonstrates. It would be so easy to let unsuccessful clients slip into the cracks and stop treatment altogether, ultimately letting them give up on increasing their quality of life. However, this method of tracking utilizes the strong community ties and support of the area in order to maximize the treatment of patients, and it takes great emotional and mental vigor to be successful.

Over the next couple days, I was also able to sit with the nurses to show them our adherence charts, and they were all very excited about how straightforward the charts are. Though the response was wonderful, such enthusiasm actually made it very difficult to present, since I know that the design isn’t quite yet in the implementable stage. They were begging for me to leave them a few charts (even secretly), but based on the Ministry of Health’s orders, I was not able to. I can only hope that we are able to get the charts to such a stage quickly, as they would allow a very simple and realistic improvement in the daily lives of many clinicians. I was also able to demonstrate the centrifuge for the first time, since they had no alternative method to centrifuge blood or test for anemia, and they seemed to like the concept, even though they were not that familiar with the need for such a device.

Being in the field, with the physical and structural constraints that we have talked about all year up to this point, was a really great experience, and I look forward to spending more days doing outreach like we were able to do with Cabrini. Seeing such different situations, surroundings, and methods of approaching healthcare is very important to understanding the greater cause of health problems worldwide. I am very appreciative of this opportunity, because I know it has already significantly changed my outlook, and know that no matter what challenges I face here, I am learning more each day than I am even yet aware of.

To stay true to Rice’s motto (“Work hard, play hard!), let’s start with a little bit of football.

Did anyone watch the US-Algeria game? What a match! Dr. Stephanie and I went to the Mbabane Club to watch the match. All of the American ex-pats were forced to crowd around a small TV in the corner of the room…the Brits beat us to the 2 big screens. But in this case, size doesn’t matter! When Donovan (aka Mr. Clutch) scored the game winner in the 91st minute, there was no question which group of fans was more enthusiastic. And plus, only one team sits atop the Group C standings and that team is the USA! Unfortunately, next up is Africa’s last hope in the World Cup (Ghana), provided Cote d’Ivoire doesn’t pull up an absolute shocker.

Now for a quick recap of our week…

Despite the fact that Dr. Oden (one of our faculty mentors) literally whizzed through Swaziland, we were able to pack quite a bit into her 26hr visit. Just hours after arriving in Swaziland, Dr. Oden was able to join us when we presented our technologies in front of a handful of public health officials, including representatives from the Ministry, the National Pharmacy, the CDC/PEPFAR, SNAP, PSI, FLAS, andd URC (to be honest, I couldn’t tell you what all of these acronyms stand for). There was quite a bit of interest in our technologies, and we even had the Head Pharmacist thinking about the “big picture” for our dosing syringes.

Later in the evening, we got a taste of authentic Swazi food (a recount of this experience to come!). If any of you ever make your way over here, I highly recommend visiting a restaurant called eDladleni in the Ezulwini Valley. The menu included wild honey (and honeycomb!), fried bananas, mealie bread, pap with corn, yams, stir fried vegetables, chicken in peanut sauce, rabbit, beef fillet with onions and mushrooms, homemade ice cream, and chocolate cake. Everything was absolutely delicious and I am really looking forward to making my way out there before I leave.

The next morning, we made a pit stop in Manzini before sending Dr. Oden off to Lesotho so that we could present the Global Focus Microscope and the DBS Transport System to Dr. Sukati, the head of the National Clinical Laboratory Services. The meeting was more of a formality (procedure is everything in Swaziland), but he seemed quite interested in adapting both technologies for use in Swaziland.

Last week, I mentioned that the very diverse staff at ICAP (awesome accents!) was interested in collaborating with us on implementing the adherence charts. Well, it turns out that we may have underestimated their excitement! When we met with ICAP again this week, we were quite surprised to learn that they were planning on printing around 600 copies of these charts, which was contrary to our original plan of evaluating the current charts this summer and modifying them as needed. Fortunately, petty politics will keep us from jumping the gun (the Ministry needs to approve these charts first). In the meantime, we will continue modifying our charts as we visit various clinics, and with any luck, we will have a somewhat polished product by the end of the summer.