Reports from Swaziland

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.

This Saturday, Ben and I had the opportunity to attend Teen Club, a fairly new program at BIPAI. In this once a month event, HIV positive kids from 10-18 come together from the community to learn healthy lifestyle and leadership skills while having fun. I was amazed by the group that showed up to the Mbabane clinic; over 100 kids of all shapes and sizes who had been looking forward to this day for weeks.

The topic of the day was disclosure, so after the characteristic songs and games of the morning, a panel discussion was held with community members about disclosure experiences, where the kids had the opportunity to ask their most personal questions. The discussion was held in SiSwati, so I was unfortunately not able to understand what was not translated for me. Where language could not be understood, however, feelings of positivity and hope were unmistakable.

We later broke off into small groups, and the kids put on short plays and skits about different disclosure scenarios. I was blown away in particular by two kids, who staged a skit about two best friends, one disclosing to the other.

A boy, just 11 years old, asked his friend what he would think if he found out if someone he knew was HIV positive. The friend responded with many of the common misconceptions of HIV/AIDS, stating that it’d be noticeable because his friend would look very sick and quickly die. The boy was quick to explain that those were incorrect notions about the sickness, and told him the facts about HIV/AIDS, explaining that an affected person might not appear to be sick and would be able to stay healthy with his medications. The friend was shocked that he had been told so many false statements about such a prevalent ailment! After the boy explained, he asked his friend again what he would think if he were disclosed to, and the answer was much more supportive. The boy then told his friend that he was HIV positive, and the friend gladly accepted him.

The day ended with a traditional Swazi meal of chicken, rice, and roasted squash and beets, and then a clinic full of participants in a “World’s Greatest” sing-along. Words can’t even begin to express how breathtaking a crowd of HIV-positive children, adults, and a whole host of community volunteers singing and hand motioning to such an encouraging set of lyrics and morals was, you just had to be there to truly grasp the magnificence of the moment.

It was awe-inspiring to see young kids, each affected with such a life-changing illness, so knowledgeable and optimistic about their individual circumstances. Though I know that the global HIV/AIDS situation is challenging, tragic, and multifaceted, I hope that with each generation, the global community is one step closer to finding a feasible solution.

They weren’t kidding when they said it gets cold over here. When the sun goes down, the temperature goes down to near freezing, and when you factor in the wind-chill and the fact that houses here have little to no insulation, it’s no surprise then that you find everyone hovering around the heater. Luckily, the temperature is quite comfortable during the day (mid-60s), and so there was no deterring Lauren and me from our stream of meetings this week.

Thanks to Stephanie and Michelle (our mentors)’s hard work and awesome networking skills, Lauren and I had ample opportunity to practice our presentation skills and flash our sparkling smiles. After meeting with representatives from ICAP on Tuesday, we headed out to Good Shepherd Hospital (a rural clinic) to present our technologies to the physicians there on Wednesday and met with the director of the Clinton Health Access Initiative branch in Mbabane on Thursday. We left one of our pediatric transilluminators at Good Shepherd (making the 3hr journey well worthwhile despite only being able to meet with the clinician for 15min) and will be going back in a couple of weeks to see how the clinicians liked using it. We also found collaborators for our transport system at the Clinton Foundation and are looking forward to working with them.

After our presentation on Tuesday, we were invited to attend a meeting today to discuss ways to improve pill counting and adherence. Unfortunately, a combination of the flu and World Cup mania has swept through Mbabane and so most of the people who were supposed to attend (including representatives from the Ministry of Health) were unable to make it. Still, Médecine Sans Frontières (MSF), better known in the States as Doctors Without Borders, and ICAP kept the party going and allowed us to unveil our newly customized, though much less colorful, adherence charts. Luckily, both parties seemed to think that our charts looked promising and its potential more than compensated for our unfortunate (how did I pass kindergarten? Oh wait, I never went!) cutting and pasting skills. ICAP has kindly offered to let us use their color printer and laminator, and has invited us to a couple of their clinics to see how the charts hold up in the field next week.

Dr. Oden is scheduled to arrive on Monday, and if all goes as planned, we will be presenting again at a meeting set up by none other than our mentor Michelle. As a final note before I go tune in to the US-Slovenia game, as you can see from our travels thus far, there are only two rules here in Swaziland: everything is on Swazi time (aka never on time) and expect the unexpected.

Here’s a picture taken when we visited House On Fire last weekend.

Cheers!

As mentioned previously, one of the technologies we brought with us to Swaziland is a chart that allows healthcare workers to calculate adherence percentages without a computer. In rural communities and outreach clinics, counting pills by hand often leads to slow or inaccurate conclusions that significantly impact ARV treatment.

This morning, we met with two members, Dr. Joris Vandelanotte and Ms. Karen Abbs, of Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP) to present our technologies. Fortunately for the community, but unfortunately for the advancement of our devices, it seemed that most of the items we brought wouldn’t be appropriate for many of the settings around Mbabane, since a good number of clinics are pretty well equipped. The search continues, consequently, to find rural communities and outreach clinics where we can gather feedback for designs like the centrifuge and hemoglobin assessment.

Though they were all appreciated, the technology that Dr. Vandelanotte seemed most excited to see was our collection of adherence charts. He said that they were a great concept, but that finding a way to account for the excess pills that patients have (when they have leftover pills from the past month’s prescription, they are usually given an entire next month’s prescription, which can skew the adherence calculation if not taken into consideration) would be even better

Our mission for the day began right then and there!

Ben and I got back to the clinic and started working, and ultimately came up with a design modification that we can present in two ways. The gist of the modification (and I hope to post a picture soon to give you a visual) is that the column where one selects ‘number of pills left’ is customizable in order to negate the excess pills from the last prescription. This is done either by displaying a certain flap or sliding a movable strip to a specific location that indicates the number of extra pills. For example, if the patient had two extra pills at the beginning, the healthcare worker selects the flap for two pills, and the place on the ‘number of pills left’ column that normally indicates one pill now indicates three.

This modification looks very promising, and we plan to take it to a rural site on Thursday to try it out. Friday morning, we’ll attend a meeting set up by local healthcare officials (which include representatives from ICAP, Baylor, Clinton Foundation, and the Swazi ministry) to discuss methods of calculating adherence. We’re hoping to show them our design, and gain more helpful feedback. Wish us luck!

Soccer. Football. Whatever you call it, it’s nothing to Americans compared to the general feeling I’ve gotten from the people here. “Bufana Bufana!” is the chant of the fans of the South African team, and though the first game is over, the horns that they sound have literally not seized since the morning of the opening of the World Cup. It’s been wonderful being surrounded by such excitement, and the parties at Dr. Hailu’s house for SA vs. Mexico as well as with the general expat community for USA vs. England were a blast. Even though I don’t follow soccer much at home, I’ve really enjoyed watching the games here, and observing the uniting force of the game (okay, there is a lot of team-bashing going on, I won’t lie).

Beyond the matches, this first weekend in Swaziland was wonderful. Saturday morning held a much longer-than-anticipated run with Brigid, but I was happy to explore some of the neighborhoods of Mbabane that I hadn’t seen yet. However, I wasn’t nearly as joyful to be chased by the Swazi alarm system- large, scary dogs. Thankfully, we made it out safely, and I didn’t have to use the mace in my pocket or test out the effectiveness of my rabies shots!

On Sunday, we joined Amy and Brigid on an adventure out to House on Fire, a B&B/restaurant/pub/plantation/craft complex in the, and it could not have been a more gorgeous day! The mixture of the earthy, hippie feeling of the complex, fair trade woven handicrafts, wonderful food eaten underneath the terrace, and views of blue skies over panoramic mountains was astonishing- definitely not what I had anticipated seeing, and surely clashing with the unfortunately stereotypical image of Africa that so many people hold in their minds. I’m beyond excited to spend the next few weeks seeing as many different sides of the country as I can, whether it be a rural village in the lowlands, or the view from the top of a mountain on this side of the country. There’s surely more to see here than I can even begin to accomplish in a mere 8 weeks, but I’m going to try my hardest to make the most of our time here, inside and outside of the clinic.

Tomorrow is the day we’ve been waiting for- the decisions and unleashing of the tentative schedule for the remainder of our time here. After discussions with the doctors, we’ll finally find out what communities we’ll be going out to and which foundations and organizations we’ll be meeting with… we’ll give you the run-down of our plans as soon as we know!

Are you ready for football?!

I know that the title of this entry probably makes some of our program directors nervous, but really, you don’t need to be in Jo-burg to feel the excitement generated from the World Cup. I woke up this morning to what sounded like loud Canadian Geese honking outside of my window. The obnoxious noises turned out to be coming from plastic horns (vuvuzela) that the local cell phone giant MTN has been giving out in celebration of Bafana Bafana (the South African World Cup team, meaning “Boys” in Zulu and Siswati). It seems like no one can contain their excitement because the horns have been constantly blowing throughout the day. For those of you who are watching the World Cup from back home, listen for the buzzing noises in the background: EVERYONE has a horn to celebrate, “Ayoba!”.

The clinic was only open for half-a-day so that everyone could watch the opening game (Bafana Bafana vs. Mexico) from home. But before I go and partake in the World Cup festivities, a quick recap of the work week (disclaimer: this blog is being posted the day after):

Though the clinic was only open for a few hours, it was a very important half-day for Lauren and me because we had our formal presentation in front of the all of the clinic doctors this morning (bright and early at 7:30am). Our mentors, Stephanie and Michelle, had us over earlier in the week for lasagna as a way to welcome us to Swaziland and to also get to see the technologies beforehand so that they could finish planning our schedule. We also met with the head laboratory tech and the pharmacists to present our technologies. From these meetings, we were able to get a lot of great feedback as to which technologies would be helpful for this particular site and what would be the best way to implement these technologies. Also, now that our mentors have a better sense of what our technologies are and have gotten feedback from the other physicians, they will be able to iron out the details for the rest of our stay. As of right now, it looks like we will be mostly staying in Mbabane and taking more day trips out to the rural clinics. They’re also working on setting up meetings with other healthcare providers working the area such as the Clinton Foundation and the International Center for AIDS Care and Treatment Programs (ICAP).

I must admit that Lauren and I were a little bit intimidated when we were immediately asked to come in and begin presenting/implementing our technologies (our orientation told us that this first week should be used for observing and acclimating). But when you have such fantastic mentors who are constantly thinking of new ways to get our devices out there, it’s hard not to get excited and to work hard to make sure we’re as productive as possible. I’m really looking forward to the rest of the summer.

But first, time some football!

Because Lauren and I will probably be referring to these “gadgets” quite a bit in our blogs, here is a brief overview of the technologies that we brought over.

Dosing Syringe – a small plastic insert that can be clipped onto a syringe to control the amount of medication drawn and dispensed. The Accudose will be especially helpful for ensuring that the right amount of medication is delivered when patients bring their medications home.

DBS Transport System – a durable system that allows for the transport of laboratory specimens in a stable environment. The transport box was originally designed to carry microscope samples but can be easily adapted for other laboratory techniques (such as the Dried Blood Spot PCR test).

Pediatric Transilluminator – allows for the visualization of hard-to-detect veins. This device is particularly useful when performing venipuncture in young, dark-skinned, or malnourished patients. We have brought over both currently available models (Veinlite) and student-made models.

Salad Centrifuge (Lauren’s baby) – a centrifuge made from a modified salad spinner that can be used to spin up to 100 blood samples to determine hematocrit without using electricity.

Automated Hemoglobin Assessment (Ben’s baby) – a two-component consisting of a photobox and computer (hopefully future cell phone app) program. The computer program determines the hemoglobin concentration by analyzing a picture of a blood spot placed in the photobox.

Pill counting scale – a portable balance that was designed to weigh out diamonds. The idea behind the scale is that if you know the weight of a single pill, you can determine how many pills there are by finding the total weight.

Adherence Charts – Determining how well patients adhere to their given prescriptions is extremely important when treating HIV/AIDS. By comparing how many pills the patient should have to how many pills the patient brings back, you can determine how well the patient has followed the doctor’s orders. These charts calculates adherence based on how many pills the patient takes per day and how days since the patient last visited.

That’s all for now. More on the World Cup later.

The summer after my freshman year at Rice, I went on an internship to Japan (http://nanojapan.rice.edu/2008_Lu,%20Benjamin.html). One thing that I found really interesting from this experience was that, even though I was familiar with Japanese culture and have family living in Japan, my perspective and understanding of Japanese culture changed quite a bit during my 12 week internship. Since I am again traveling abroad (but this time to a country that I am much less familiar with), I thought it would be interesting to jot down everything I know about Swaziland and the Swazi people coming into the program and see how these preconceptions change. I am a little embarrassed by how little I actually know about Swaziland (not to be confused with Switzerland), but by the end of the program, I hope that I will be able to say much more about the Swazi people and their culture.

As any travel guide will tell you, Swaziland is a small country landlocked in South Africa and is approximately the same size as New Jersey (so I’ll be right at home). Swaziland is one of the few remaining true monarchies in the world. The Swazi people originate from a single, mostly homogeneous tribe. As a result, Swazi culture in general is rather conservative and etiquette/tradition is important (reminds me a little bit of Japan). Unlike Japan, the Swazi men are polygamous. Siswati is the native language of the Swazi people; however, like its neighbor South Africa, Swaziland is a former British colony and so English is universally spoken. Like many sub-Saharan African countries, maize and cornmeal are staple foods. Though Swaziland is considered a middle-income country, it has the highest prevalence of HIV/AIDS in the world. As a result, the average life span has dropped dramatically in the past 30 years.

What a full week it has been so far! Our first few days at the clinic have been filled with observing DBS (dried blood spot) tests, blood draws, pill counting and patient adherence calculations, and all the other goings-on of the clinic. This includes conversations in SiSwati, some of which we have been trying to pick up on. Sawubona, for example, is the usual greeting when you see someone- it’s very exciting to learn! In response, you say yabo (yeah-bo). How are you is unjani, and then you say ngiyaphila (nee-ya-peel-a). I’m having some difficulty with some of the names of the staff at the clinic, as I’m having to learn entirely new sounds and syllables… let’s hope I can start picking it up soon! It’s especially helpful because some of the volunteers here have been giving us lessons when we’ve had free time.

Ben and I are watching these procedures to understand not only how the procedures are done, but the details of what is necessary to carry out such procedures, which is the information that will help us most with maximizing the benefit of the technologies we brought with us. To give a brief explanation of the technologies and observations so far (I believe Ben is giving more description about them in his blog), I will let you know that we brought 7 different designs from students:

1) Pediatric transilluminator that allows visualization of hard-to-detect veins- should be very helpful, and we will start letting the staff use them to see if they like them

2) Dosing syringe clips that control the amount of liquid medicine that is drawn and dispensed- pharmacy and doctors are very excited about these, as liquid medications for children are often inaccurately given

3) Transport system for laboratory samples that need a durable and controlled environment- though it won’t be used for just DBS tests like we had envisioned, we are discussing making different inserts for different types of tests and outreach clinics, which could be very helpeful

4) Salad spinner centrifuge that can determine hematocrit without electricity- unsure whether or not this would be useful in the rural areas, so we need to investigate different sites, but it wouldn’t be necessary in any clinic that has a lab, like this one

5) Automated hemoglobin assessment that analyzes a picture of a blood sample using a cell phone- waiting to hear from more doctors to hear where this might be best used

6) Adherence charts that simplify the calculation of patient adherence- could be beneficial if we adapt the design to suit the most commonly prescribed regimens

7) Pill counting device that maximizes efficiency in dispensing and counting tablets- have found problems already, mostly because medicines used for treatments are much larger, so counting on the scale is not very time-effective

We have been beginning to introduce the technologies to the doctors and staff here, and it seems that they will be very receptive to hearing our ideas, which is great news. We spent three hours explaining all the details of the devices, or “gadgets” as they’ve been calling them, to Michelle and Stephanie the other night, and we’re beginning to plan our rural community clinic trips, meetings with NGOs and other local organizations, and our dissemination of the technologies in the Mbabane BIPAI clinic itself. On Friday, we’ll be giving a short presentation about each of the technologies at the doctors’ meeting, and then meeting with Dr. Hailu, the director of the clinic, to determine that work that we’ll carry out over the next two months in Swaziland. I’m very anxious to figure out where we’ll actually be located during our stay, which will hopefully include trips to various rural communities with different constraints.

Beyond our work at the clinic, we’ve been able to experience a little bit of the doctors’ and expats’ lives here, which included my first attempt at Ultimate Frisbee last night. They’ve created a group, which includes some locals, too, called the Mbabane Mbananas, which makes me laugh every time I think about it. While I gave the game my all for the first while, I decided to stretch my legs in a more tried-and-true way to me by running laps around the field that we were playing. It felt so great to feel the cool night breeze, especially compared to the hot and humid Texas summer weather! After that, I joined in the last small game, and really enjoyed it the second time around- I have the catching part down, now I just need to get the throwing! We went to dinner afterwards with Michelle, as well as two of the medical students here at the clinic, Amy and Brigid (they’re actually both former peace corps members that were stationed in Swaziland that decided they really wanted to come back!), and thoroughly enjoyed the night. This weekend, with the beginning of the World Cup, we’ve been invited to two different viewing parties! On Friday, we’ll be going to Dr. Hailu’s house with the rest of the doctors and visiting scholars (which is what we and the medical students are called), and on Saturday, we’re going to a restaurant with the larger expat and Mbabane community- I think it will really be a great time, and I’m sure we’ll be able to meet very interesting people.

I’ve been wanting to upload pictures to the blog (Ben has successfully gotten a couple up), but the internet has been so unstable that it hasn’t been able to load any of my pictures yet. I’m going to work on it more and hope for the best, because I’d really like to share the sights of the city and our adventures. I’ll update again after what sounds like a productive meeting and exciting World Cup shenanigans!

After 40+ hours of travel, we’re finally in Swaziland!

The trip was definitely long and tiring (6hrs Newark to London, 12hrs layover+2hr delay, 11hrs London to Johannesburg, 3hr layover, 50mins Jburg to Manzini), though we did get to hit most of the big spots in London (including stumbling into the Swazi embassy) and got a small taste of the World Cup when wandering the Jburg airport. For the trip from Jburg to Manzini was unique, we took a small charter, plane, which we boarded from the runway.

As long as the trip to Jburg was, the flight from Jburg to Manzini was over in a breeze. The flight time was literally only 5 minutes longer than the time it took for us to board the plane. In all fairness, boarding took longer than usual: from our gate, we took a bus that drove us out onto the runway where we boarded a small, charter plane. Literally, the moment the flight attendant passed me the bag of Fruit Chutney Potato Chips (which were surprisingly tasty…imagine an African BBQ flavor), the pilot informed us that we were beginning our descent and so had to “stow away our tray tables and put our seats to their upright positions.”

Hello Swaziland!