Reports from Swaziland

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.  

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.

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!

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.

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!

This blog is being written to recount my travels in Swaziland as a part of the Beyond Traditional Borders (BTB) summer internship program. The BTB program is the undergraduate global health technologies program at Rice University. This summer, Lauren Theis and I will be traveling to Swaziland to present and/or implement various medical technologies created through our program.

As of right now, I will be spending the first and last 4 weeks at the Baylor International Pediatric AIDS clinic (BIPAI) in Mbabane and 4 weeks in a rural satellite BIPAI clinic (specifics are still being arranged).

I am really looking forward to this summer and hope you enjoy reading my blog.