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.

After much discussion with the doctors and executive director at the Baylor clinic, and several trips to outreach clinics, I have found a home for the “Lab-in-a-Backpack”. We all agreed that the backpack would not be of maximal use at the Baylor Clinic, as they have full lab capabilities and enough money to purchase equipment of their own. We wanted to find a home that really needed the backpack. After several suggestions by the outreach doctors, I decided to leave the backpack with a “group” that has, literally, no lab capabilities, does almost exclusively primary care, and has a wonderful relationship with the Baylor clinic. It is my pleasure to introduce you to “The Luke Commission”:

According to Colossians 4:14, Luke was the “beloved physician” of the first century. Luke wrote one of the four gospels, and the book of Acts. This ancient physician was the first inspiration for the foundation of The Luke Commission. The second inspiration came from The Great Commission, the final command given by Jesus in the last chapter of the book of Matthew:

“All authority has been given to Me in heaven and on earth. Go therefore and make disciples of all the nations, baptizing them in the name of the Father and the Son and the Holy Spirit, teaching them to observe all that I commanded you; and lo, I am with you always, even to the end of the age.”

With a leap of faith, Harry and Echo VasderWal gathered up their triplets and two-month-old baby, and headed to Swaziland to combine their two greatest passions—medicine and God. A few years later, The Luke Commission, a non-profit 501(c)3, was born in an effort to practice “compassionate medicine”.

The couple has treated more than 50,000 patients, have distributed at least 350,000 packets of free medication, and have fitted 17,000 people for reading glasses. Thousands of school children have received school supplies and vegetable seeds to grow in their school gardens, 20,000 orphans and new mothers have been clothed with new outfits and shoes, and 13,000 Swazi Bibles have been distributed.

The Luke Commission team travels thousands of kilometers each month to deliver medical, HIV, vision, and spiritual care to the sickest and most forgotten. Clinics are set up in orphan care points, chief kraals, rural schools, community centers, and churches. Hundreds of Swazis are greeted and told “everything today is free, thanks to donors in North America,” Patients are triaged. Blood pressures and sugar levels are taken. Prayer is offered. Each patient is treated and given free medications labeled in SiSwati. Voluntary HIV testing and counseling is offered. Follow-up care is coordinated with the Baylor clinic for HIV positive patients. Patients with vision problems are tested with an autorefractor and fitted with eyeglasses from an inventory of 3,600 pairs. AIDS orphans receive new clothes. Extended care is spearheaded for patients who need surgeries, wheelchairs, crutches, cataract operations, and long term medication for HIV. The VanderWals have learned the power of Job’s words, “Have not I wept for those in trouble? Has not my soul grieved for the poor?”

The stories of the treatment that The Luke Commission has provided are the most incredible testament to their compassion:

“A 9-year-old boy had endured fungal infection on both feet for a year. His 20-year-old mother brought him to a The Luke Commission clinic. An orphan herself, the young mom cared for her bed-ridden grandmother and did not have the money for medicines. She wept when her son received treatment and free medication.”

“Breast infections are common among women. Echo saw the worst infection when a 54-year-old lady sat down in front of her and unbuttoned her blouse. The lady’s chest was oozing, soiled rags stuck to her skin. Echo soaked off the rags and cleaned the wound. She lathered the breast with antibiotic cream and gave the patient ointment and antibiotics for two months. ‘Meet me at the hospital in two months, and we’ll give you more medicine’ Echo advised.”

Many rural Swazis are unable to afford transport to the city to see an optometrist and purchase corrective lenses. The Luke Commission uses autorefractors to test the eyes of patients and determine what prescription is needed. Each patient is then matched with a pair of glasses. It makes no difference that an old man has rhinestones on the corners of his glasses of that a 16-year-old boy has prescription glasses that look like cat eyes. The Luke Commision’s inventory of eyeglasses has made two more matches that enable these Swazis to see. “I can see that blade of grass,” an elderly man exclaimed. “No more living in the shadows.”

“Leaning heavily on stick canes, two elderly women walked 40 kilometers to have their eyes tested. Neither had seen well for years. The two-day journey meant they slept along the way when night fell. The eyeglass line was long when the women arrived at the clinic, but they were determined. Finally, their turns care. The autorefractor indicated one lady needed glasses with a plus-power of 11; the other needed a 9 plus-power. Those are difficult prescription requirements. However, minutes later bother pairs were located in The Luke Commission inventory. ‘I do not know where to look first. All the colors are so beautiful,’ declared one of the women.”

Dr. Bitchong, the Chief Medical Officer at RFM Hospital in Manzini, says about The Luke Commission, “[They are] playing an important role in Swaziland, not only on health service delivery but also on making Christ known to many Swazis.”

Perhaps Paul describes their mission best, “Therefore, strengthen the hands that are weak and the knees that are feeble, and make straight paths for your feet, so that the limb which is lame may not be put out of joint, but father healed… Do not neglect to show hospitality to strangers, for by this some have entertained angels without knowing it.” -Hebrews

With a team of trained Swazi translators, the VanderWal couple sees almost 600 patients every Monday, Wednesday, and Friday. Their eyes lit up when they saw the pulse oximeter, the glucometer, and the urinalysis strips. They very willingly agreed to provide tons of feedback about the backpack, and were delighted to show me around their house / headquarters. The backpack has found a perfect home – or rather, a perfect home has found the backpack.

I have discovered that faith is a powerful motivation for many people in Swaziland. Their faith comes in all shapes and forms. For many, their faith is grounded in God. For others, their faith is revealed as they wait patiently in the midst of a drought, as they relentlessly care for their baby sister and grandmother, or as they face HIV with fierce optimism. This weekend, we had the pleasure of meeting a wonderful family grounded in faith. Rudy, the father of the family, was a Peace Corps volunteer in Swaziland in 1997, and decided to return to his homestead with his family in 2002. He lives in a rural village, and works as a government school teacher, with his wife and three children: Faith, Hope, and Grace. I soon discovered that these are more than just names for the family – they encompass everything that the couple has discovered in Swazliand. Faith. Hope. Grace.

“Now FAITH is the assurance of things hoped for, the conviction of things not seen.” – Hebrews 11:1

“Let us hold fast the confession of our HOPE without wavering, for He who promised is faithful.” -Hebrews 10:23

“My GRACE is sufficient for you, for power is perfected in weakness.” – 2 Corinthians 12:9

Faith, hope, and grace are a universal language. Perhaps Aslan says it best:

“‘You come of the Lord Adam and the Lady Eve,’ said Aslan. ‘And that is both honor enough to erect the head of the poorest beggar, and shame enough to bow the shoulders of the greatest emperor on earth.'”

—Prince Caspian

Although the Baylor Clinic’s primary focus is on clinical care, they have discovered the merit in providing psychosocial care as well, especially in the adolescent age group. Adolescence can be a complex transition from childhood to adulthood, and is marked by rapid growth, sexual maturity, and development of more complex reasoning and abstract thought. Adolescents are assuming more independence and exploring the difference between right and wrong. Peer interactions are extremely influential in their daily decision making.

During this challenging time, access to structured, group support systems allows them to develop a positive self esteem, make healthy decisions, and become productive adults. To help during this difficult period of transition, Baylor has initiated an adolescent support group that meets every month to provide adolescents with HIV with the support that they need.

Over the last three years, the Baylor Adolescence Support Group has grown to around 120 participants between the ages of 10 and 18. Preadolescent and adolescent patients gather on the third Saturday of every month in a session that is facilitated by the clinical staff. The goal is to make the support group productive, fun, and educational. The day starts with a short clinic that allows the kids to receive their medications, avoiding missed school days. This is followed by support group activities, including arts and crafts, dramas, debates, games, and discussion of important topics. This month, the discussion topics were sexual development, reproduction, and positive prevention.

Yiwen and I were in charge of planning and facilitating the activities and discussion. Last month, the students requested that this month’s topic be “sex and dating”. Before we began the curriculum, we wanted to make sure that everyone was comfortable with the topics. For the first activity, we ask the participants to put aside their fears of saying taboo words during this exercise, explaining that we must learn to talk about various sexual parts of the body and different sexual behaviors appropriately in order to protect our health. We emphasized that it’s important to be comfortable talking about sex and its consequences with your partner and with your peers.

It was obvious that that many of the teens (as in America!) find it embarrassing to discuss subjects that touch on sexuality and its consequences. However, when dealing with topics such as sexual health and HIV, we MUST be able to talk about sexual attitudes, behaviors, and the consequences of unprotected sex. We felt that it was important for the audience to feel comfortable with the language that was being used. So, we divided the room up into seven groups, gave each group two “sex terms”, and asked them to list synonyms, slangs, or SiSwati translations of the words. Each group presented their lists, and—after tons of laughter—we decided which words were going to be used in the classroom, at home, and with partners.

For the second activity, we asked the entire group to help us list changes that boys and girls experience during puberty. Several minutes were spent discussing whether or not girls develop body odor.

Finally, we had two teams work together to draw the male and female reproductive systems, and compared them to textbook diagrams of the reproductive systems. This activity provoked tons of questions. Five or six boys asked wonderful questions about menstruation. Is it painful? Why is it painful? When does it end? Why is there bleeding? When is ovulation? As it turns out, the teens almost unanimously thought that the bleeding was caused by the bursting of the egg.

This was the first of three months that will be spent on sexual development, reproduction, and positive prevention. The clinic was thankful that we had developed curriculum and activities for the next few months.

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.

I tend to get sick only when I’m surrounded by the world’s best doctors. I’ll count myself blessed. I wish I had a more exciting account to give of this weekend. Unfortunately, Yiwen and I spent the weekend at the hospital—me in the hospital bed, Yiwen relentlessly and kindly taking care of my every need. Have you ever thrown up for twelve hours straight? By 7:30am, I decided to get some help. Luckily, my cell phone was pre-set with fifteen of the world’s best doctors. Michelle took me to the hospital straight away, where they gave me two bags of IV fluid, a few shots of goodness knows what—I’ll call it make-this-vomiting-stop-ycycline—and two pain killers that removed the jackhammer from my skull.

Don’t worry, the hospital was very sanitary and safe. Several of the PAC doctors have even had babies there. At that point I didn’t really care. I was sure I was on my death bed, hallucinations and everything. Michelle marched me right into the hospital and began to write down exactly what she wanted the doctor to give me in list format with the correct dosages next to each medication. She is a wonderful doctor. Whatever it was (not malaria or typhoid) went as fast as it came. After a few hours at the hospital, and 3L of Energade, I was already 90% better. Michelle deciphered the lab report for me, and decided that I had some sort of bacterial gastroenteritis. I was comforted by the receptionist who told us of four other admissions to the hospital that morning with symptoms identical to mine. It was nothing to be worried about—probably just a bacterial infection that I had no resistance to.

As the saying goes, health is often not valued until sickness comes. Right now, I am thankful to be eating, running, working, and spending the evening playing “Actionary” with friends.

Life Is Good.

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 becoming increasingly interested in the diagnostic capabilities of both the Baylor clinic and their outreach sites. I was able to spend the entire day yesterday at one of the rural outreach ART clinics. The one doctor and I spent 8am-7pm seeing 27 patients, 9 of which were “new ART initiations”. Five babies had their blood drawn (without a flabatamist), and one family waited, literally, the entire day only to find out that they had been directed to the wrong line. Of course, Michelle did the best she could to see treat the family. I don’t think it’s necessary to describe the condition of the outreach clinic. A description wouldn’t do it justice anyhow. Imagine a hybrid of a jail and a homeless shelter and you’ll be close enough.

The diagnostic capabilities at the clinic are astonishing. They are able to perform CD4 counts (without percentages, so the nurses must use the numbers to calculate this), LFTs (Liver Function Tests), FBC (Full Blood Count), DBS tests (to send to a PCR lab) and HB (Hepatitis B) tests. However, they do not draw blood from patients younger than 5 years of age—they refer these patients to the Baylor outreach doctor that comes once a week.

In continuation of my investigation of PCR capabilities in Swaziland, I have discovered that they have a PCR machine in Swaziland. It is barely being used—the rumor is that it is being “tested”, whatever that means. Still, sending samples to the lab in Swaziland only decreases the turn-around time by one week (from 6 weeks to 5 weeks), not decreasing the turn-around time enough to keep the patients from returning more often than their four week follow-up visits. Perhaps prioritized sampling could solve at least part of the problem—children with extremely low CD4 counts, and clinic symptoms of HIV could have their tests expedited. However, the protocol for prioritization would have to be so subjective that this might not be a possibility. They rarely do RNA PCR at Baylor—10-15 times a month—and send their samples to a private lab for results.

This morning, Yiwen and I presented our projects at the staff meeting. There were several gasps and whoa’s as I unzipped the lab-in-a-backpack. They are VERY excited about the backpack, and are eager to find a home for it. We decided that it would not be of maximal use at the Baylor clinic (most of the work is HIV-related, and they do not do outreach to clinics without lab capabilities—yet). However, I have been directed to several doctors working in the most rural parts of Swaziland. I am most interested in pursuing a husband (doctor) and wife (nurse) team from America, working in a rural community of basket-weavers (Gone Rural Bomake). As of right now, they are the most likely candidates to provide feedback on the use of the backpack.