Reports from Swaziland

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

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

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

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

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

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.

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!

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!

Sawubona, my avid blog readers! I am happy to announce that after a grueling 40 hour process, Ben and I are safely in Mbabane, Swaziland. The trip over here was successful, save the security-confiscated wire cutters, baggage overage fees encountered three fourths of the way through the trip, and the overarching theme of “no sleeping.”

I got off to a great start from San Antonio to Houston, and then onto London. Once in London, after our previously arranged meeting plans were foiled, I managed to find Ben waiting for me at the conjuncture of connecting gates and customs. Fortunately, we didn’t have to pick up our baggage in London because it was tagged through the airline switchover, so we grabbed our London Underground day passes and decided it was time to tour the city!

We stretched our tired legs with lots of walking, tourist picture taking, statue climbing, and some fish and chips. We loved it so much that right after we stepped food in Swaziland, we went straight back to London! Okay, that was intentionally a little misleading. While walking to find lunch in the city, we stumbled upon the Swazi Embassy… it was fate, and comforting, because even in the worst case scenario, we had already made it to Swazi territory!

The London-Johannesburg leg allowed us to close our eyes for longer than a few minutes, which was great because of the headaches we’d encounter with security and baggage re-checking. We made it out alive, and then it was on a tiny plane and taxi all the way to Mbabane! We’re here now, and were fortunate enough to meet some of the doctors, nurses, and members of the clinic already, and are starting to get acquainted with the town. Mbabane is beautiful, by the way- sunny, green, and lush!

Tomorrow we’re headed to the clinic in the morning to start observing to find out what all they do in the clinic, and at night, we’ll join Stephanie and Michelle for a home-cooked dinner and discussion of all of our technologies. I’m very excited to be here, and the realization that we are actually here is starting to set in!

I know it will be a great challenge, and I am looking forward to everything ahead of us, no matter how difficult or uncomfortable, because I already know it’s going to be a rewarding experience. Maybe not as instantly gratifying as the good night of sleep I am about to get once I’m finished writing this, of course, but definitely something that will stick with me for the rest of my life.

I’ll leave you with a few facts of life we have learned so far:

1) There is a “right hand rule” in Swaziland… everything must be done with your right hand, including handing money over to your taxi driver. If you try to give it to him with your left hand, he won’t accept it.

2) The drinking water in Mbabane is reliable… I hope I don’t regret making that claim, but the resources available in the capital are definitely sufficient. I’m not sure how quickly those availabilities disintegrate in rural areas, but I’m curious and will soon find out as we move into our rural clinic.

3) The Southern African regions have a standard handshake… you shake hands normally, but then slide your hand up and squeeze, and then go back down and shake the hand normally again. It takes some getting used to, as it seems like the person you were just introduced to is trying to make a secret handshake, but apparently it’s not so secret!

Thanks for reading, and be sure to check back in soon for an update about our time at the clinic!