What's Happening in Swaziland

This is what's happening in Swaziland!  "What's Happening" is a monthly entertainment guide (targeted mostly towards the tourist crowd) analagous to the Gambit Weekly or Where Y'at in New Orleans.  It gives suggestions of places to visit and special events going on around the country. 

Some of these are quite similar to the web images we found for the previous post, but here are some of the pics we took during our first weekend of sight-seeing with Mac and Nancy.

Kate's beautiful bedroom at Mac and Nancy's house outside Matsapha:

Ngwenya Mountain - It really doesn't take that much imagination to see the crocodile (though Mac swears we're all crazy and that it's really not there!).  The tail is to the left & the head (and the bumps that are the eyes) to the right, just past the power pole.  There is a mountain in the background as well that somewhat obscures the profile of the back & tail:

Hand-blown glass elephants at Ngwenya Glass Factory:

Cool lamp(shade) at Quazi Designs, a shop next to the glass factory where everything they sell is made from recycled magazines.  They sell beautiful jewelry (earrings, bracelets, & necklaces of several varieties) as well as funky home decor:

The lake created by Maguga Dam in northeastern Swaziland.  We enjoyed delicious "cold drinks" on the patio of a restaurant with this view.  It was especially nice because the day was so warm, nearly 90 degrees - - a pretty significant change from our normal weather in the mountains of Mbabane (where we're staying):

the mighty Maguga Dam:

Glamour shot in the 90 degree heat!

 

The now famous Mac and Nancy, our Swazi godparents & supreme tour guides:

Elephant candles at the Swazi Candle Factory:

Enjoying the first try of miele (corn roasted in the husk & sold on the side of road).  It tastes like a cross between traditional corn on the cob & popcorn.  You'll notice that where the corn kernels aren't darkened (near the ends), it's white kernel corn.  Apparently in Swaziland, yellow corn is only for livestock!

Freshly Ground, the South African group, entertaining a lively crowd at House on Fire:

Demonstration of the Swazi Baby Bjorn with the an additional toddler on the left hip!

Weekend Adventures #1

Pictures that we took will be coming soon....but in the meantime, I have a little free time on my hands as I unwind for the evening, so I thought I'd post a little bit more upbeat news than medical-speak.

Carter & I had a great weekend with our Swazi godparents, Mac & Nancy.  Mac picked us up from the clinic in Mbabane & whisked us off to their home near the airport where we arrived.  They live just ouside of an industrial town called Matsapha (which is close to Manzini - the biggest city in Swaziland though the capital is Mbabane, where we are).  We got situated in our rooms, freshened up, & went off to dinner with Mac & Nancy in the Ezulwini Valley area (our guidebook compares it to Las Vegas though I think the few casinos in the Valley are the only real basis for comparison.....and even that is a pretty loose connection as the casinos are nothing like the lights of Vegas).  We had a delicious dinner at one of the casino restaurants & then headed home & to bed shortly thereafter.

Mac & Nancy have a lovely home with a great view of a "dam" (in the States it'd be called a reservoir - it looks like a bayou/large pond though I believe the one in their neighborhood is man-made).  Although they have a great backyard (where we have already spent a good bit of time conversing & enjoying meals), I think my favorite part of the home is the huge bathtub in the guest bathroom.  I can't remember the last-time I could actually straighten my legs & lean back at the same time in a tub!

After getting ready for the day & a delicious home-cooked breakfast, we headed out for day 1 of sight-seeing.  We started at the Ngwenya Glass Factory, named for the crocodile-shaped mountains where it is located (ngwenya is Siswati for crocodile).  It took a little imagination to actually see the crocodile in the mountains, however, & Mac swears that we're all crazy because he can't see that shape in the mountain peaks.  In any case, using all recycled glass, several Swazis use traditional glassblowing methods to create beautiful pieces, from decorative to functional, which they sell in the adjoining shop. 

Unfortunately, none of the artists was working when we were there but we did get to see the end-results & they're quite impressive.  In the same complex, there are also a number of other small shops selling Swazi-made handicrafts varying from beautiful mohair scarves to rocking horses (and rocking zebras!).  We browsed the shops & then sat for a little while to enjoy the view & a snack.

From there we continued north to the Maguga Dam, a huge man-made dam/reservoir that was jointly funded by Swaziland & South Africa (the latter because it helps supply water to part of that country as well).  It was a hot day, & the water looked quite refreshing....we settled for the shade of a cafe overlooking the dam. 

There were very few boaters out on the water (it's apparently pretty good for fishing bass) as it was early-afternoon by that time & the sun high/hot.  After a cold drink in the shade, we headed back towards home, picking up ribs & lamb chops at the grocery store to grill for the evening.  We had another delicious dinner & then curled up on the couch for a movie before bed.

This morning a cold front had finally rolled in so the air was cool & the weather perfect.  We had breakfast on the patio & then headed to the Swazi Candle Factory, not too far from Mac & Nancy's place, to see a few more local artisans/markets.  From there we moved on to a unique concert venue/restaurant complex: House on Fire and Malandela's.  House on Fire was originally an outdoor amphitheater that they eventually added onto, little by little, with unique & artsy (& kitschy by some tastes most likely) additions.  It is now a round, wooden, rustic looking structure filled with colorful arts.  Today's concert, however, was on their lawn (a la Jazz Fest style but smaller.....more like one of the grass stages at French Quarter Festival, for all the Nola readers).  It was overcast & a bit drizzly at times, but really it was perfect weather to be enjoying the afternoon outdoors (especially since yesterday was so warm)!  We had a leisurely lunch at the restaurant, Malandelas, which faces the lawn/concert stage & listened to a few acts.  (Billy, they had a shortened menu for the concert that afternoon but Mac & Nancy think you must mean that we should have the Camembert at Calabash...which is supposed to be our farewell dinner at the end of the trip.) 

The main act at the concert this afternoon was a group from South Africa called Freshly Ground.  The doctors we are working with here had told us about the group & concert....their best idea/description was a cross of soul & pop of sorts.  I'm not sure what a more accurate description would be, but it was good music.

And now we're back at our cottage for a little unwinding & getting ready for the week.  It will be a short week because of Easter (we have both Good Friday and Easter Monday off of work because the clinic is closed), and we will spend half of the time sitting in on the HIV lectures that are happening as part a nurse's training that is happening this week in Mbabane.

Hope all is well back in the States...have a good week!

Your Guide to Creating Your Very Own Swazi Baby Bjorn

Better than most women around the world who improvise their baby carriers, Swazi women carry their infants & small children on their backs using bath towels (normal size ones, that barely wrap around your hips or your chest, depending on your body shape).

And, they do it successfully. We thought you should all be imparted with this wisdom because it works! Amazingly! Kate tried it, & I documented the 5 steps for your learning pleasure:

Step 1: Place the baby on your back - the only real requirements for this are that the hands/arms be directed toward your head/neck.

Step 2: Flip the towel up over your back to drape over your back & the baby's body (should go from about the baby's shoulders as far down as the width of the towel).

Step 3: Wrap the top of the towel around your body, under your arms, as if you were tucking a bath towel around your body after the shower.

Step 4: Gather the bottom corners of the towel in each hand & cross the bottom left side around your waist to your right hip. At this point the towel will be gathering below the baby to form a "seat."

Step 5: Tuck the bottom right side underneath the wrapped portion of towel (the same as you did on top but this time tucking from bottom up). You can tighen as needed by pulling the wrapped portion tighter.

Voila! Success:

After the wrapping, some women pull their babies feet out to hang loose (depending on the size of child & the length/flexibility of their legs). Also, the moms who are bustier or just bigger in general will tie both the top & bottom of the towel in a simple knot (not even a double knot) instead of tucking, & it works the same way. Just imagine how easy this would be with a beach towel and not a bath towel!

"Slim" Clinic

I suppose because of the wasting effects it has on the body, HIV is known in many parts of Africa as " Slim."  Even more than slim, it would better be called "Slim & Short" as so many of the patients we see are not only slender (from a combination of illness, malnutrition, and so on) but also very short and appear much younger than their actual age.  "Slim" better describes the adult and/or adolescent population who acquire HIV horizontally (sexual transmission or from other body fluid mixing) as those patients end up wasted from the virus and coinfections that result.  The children, however, who are infected with HIV vertically from their birth have bodies that are ravaged by the virus their entire lives - - often times for much longer than they may even know (for sure) that they are HIV positive.  Of all the children whose heights I measured today in clinic (which was only 4-6), ages probably 10-13, no one was taller than 133cm (which is about 5 feet...and doesn't seem so short now that I type it, but it definitely was for the older kids).  It's kind of impossible to know exactly what all of the detrimental effects HIV is having on the bodies of these children....things like HIV disease of the kidney don't even really enter into the train of thought here so far because the patients are far more likely to suffer and/or die from an opportunistic infection (simple or complex).

Speaking of opportunistic infections (secondary infections that wreak havoc on the bodies of immunosuppressed patients like those with HIV because their immune systems aren't strong enough to fight the new diseases), the CD4 count is such a huge part of managing HIV (wherever the patients are).  Here in Swaziland, though, they don't typically refer to it as CD4....instead they call that subset of white blood cells that fight infection soldiers....and the CD4 count is thus the "soldier count" - for both children & adults.  It's simple but it seems to be a very effective way of helping the patients understand what's going on....and it perhaps makes it mean more to them than the more technical term "CD4 count."  I think it must make it easier to remember that number - something which many patients back in the States don't pay attention enough to remember.  Treatment for adults (and kids over about 12) usually starts with antiretroviral HIV meds when the CD4 level drops to 350 (or in some cases 200) because that is when patients become significantly more susceptible to opportunistic infections.  In medical school, classmates often compare their patients (in generic, non-identifiable, HIPAA-compliant ways) - what was the CD4 count and what did they have (something like I had a guy whose CD4 count was 10 & he had crypto meningitis and pneumonia and....).  Here in the pediatric population (whose CD4 count needs to be higher to fight off infections), it's not at all uncommon to find CD4s ranging from 10 to 100 to 300, even after they'd been getting medications for the HIV for a few months.  I've had relatively few patients with CD4 counts greater than 500-900, the latter of which is just below the cut-off for treating infants with HIV meds.

Hopefully all this information is not too disheartening, but as sad as it may be, it's reality for many people.  If the worst of the HIV/AIDS epidemics have hit across the world, we are lucky but still have a lot of work to do/culture to change.  While our 4 weeks here may not make a big dent in that change, the 3 days of clinic have already been huge for broadening our exposure (and it's not like HIV & co-infections are uncommon in New Orleans).....I've seen almost 10 cases of the measles.  I had always imagined it to be a chicken-pox like disease, & while they're both viral, the rash from measles is totally different & pretty subtle (especially in a dark skinned child)....the bright red injected eyes, however, are impossible to miss.  The current generation of babies is apparently getting vaccinated for childhood illnesses fairly decently, but the older children & adolescents/adults have often not been vaccinated for things like the measles so it is easy imagine that entire households may be sick together because the virus is very contagious.  The worst of it has been a 12 year old boy who was admitted to one of the hospitals with measles (and HIV) and a cough....and whether it's a new superinfection or something that had long been underlying, he now most likely has multi-drug resistant TB and/or PCP (a pneumonia seen in HIV patients).  We're hoping for the best, but the string of diseases along with the HIV has left him so malnourished that his upper arm is not any bigger than his humerus & a layer of skin...his hands are the only part of his upper limb that tell you he is not a small child of 7 or 8.

Other clinic patients have been a variety of TB, a possible case of gout in the hand (gout would probably actually be a good diagnosis because it's relatively manageable.....because any infection making her hand swell so much would not be a nice one) , and a few new-diagnosis/positive test result counseling cases.  We had a 12 year old boy (whose parents have both died in the past few years) living with his grandparents who was tested recently when he was sick & was found to be positive.  He was pretty well educated & handled the information about the virus & his soldier count very well....but it's sad that the prevalence & spread of HIV is so extensive that his life experiences at age 12 have already prepared him decently well to take the news & go forth in evaluating his health.  Also today, we sent another baby to the hospital - unlike the 10 day old with HSV (which was very sad but clinically very interesting/unique to see), this baby was about 5-6 weeks and did not get treatment as a neonate because she was born at home.....so her HIV status is unknown but clinically presumed to be positive because she has fever, oral thrush, failure to thrive/grow, diarrhea as well a cloudy CSF on lumbar tap.....the only thing that might be a beacon of hope for this babe is that when we drew her blood, her white blood cell count was high (23 I think) - which normally is a bad thing, indicating a rip-roaring infection - but shows that her body is at least able to mount some form of immune response.  So, we'll cross our fingers that she will improve in the hospital & be HIV negative (and also not have a varicella/zoster infection since her mom had shingles during pregnancy....and apparently IV acyclovir is next to impossible to get in Swaziland).

This was a long post, but we're seeing & learning a lot of amazing things.  To make up for the serious nature of this one, however, perhaps Carter & I will try to post a little cultural lesson later.  We're slowly picking up a few words Siswati.  We haven't had many adventures with fun pictures since Sunday (because we've been working), but we may be able to work up some fun stuff showing off our "office," Carter's yoga "studio," and the mode of baby-transport/Swazi baby carrier demonstration.  Other big news - we found the local gym today, which is actually quite nice, so we got a little exercise.  Also, this weekend will be full of adventure as we embark on the first round of Swazi sight-seeing with Mac & Nancy. 

Before I end this blog (sorry, I'm long-winded) I will explain who Mac & Nancy are for those of you who don't know (of) them.  Via my cousin Craig, I have lovely friends in Raceland, LA (Billy & Louise) who are my local go-to guardians/advisors when I need help or information.  Billy, an engineer, eventually switched from engineering stuff to sales for the company where he worked (they make tractors & other large farming equipment)....and his territory included much of Africa.  So, he has travelled here in Swaziland as well as other parts of Africa reasonably extensively, and along the way has made a number of good friends (as his Bayou-born nature)....one of whom is Mac, a retired farmer here in Swaziland.  Mac & his wife Nancy are already our Swazi god-parents....they met us at the airport just to introduce themselves & make sure we arrived safely.  Mac has also been by the clinic (both before we arrived and since) to make sure everything here & our situation was secure.  And, this weekend the spoiling will begin (just like grandparents!) as Mac called to let us know earlier this week that they would come pick us up on Friday after work so we can stay at their house & relax & sight-see about Swaziland & the surrounding areas.  As my mother would say, not to count our chickens before they've hatched, but this will likely be a regular weekend activity for us over the coming weeks!  We will post pictures next week after our adventures, but for my family, Mac reminds me significantly of Knud (in appearance, profession, & demeanor).

Malnutrition & Dehydration

Today was slightly less busy at the clinic. We saw a ton of patients, but fewer that were critically ill. The one exception was a 8 month old little boy who was brought in by his mother looking very sick and undernourished. Apparently he was being cared for by his grandmother because his mother had taken a job as a live-in nanny in a town far away from where they live. While living with his mother during his first few months of life he was breastfeeding and growing well. Since he has lived with the grandmother he has been formula fed, but apparently not enough. The cause is likely due to poverty, but there may be a social component too with the grandmother not really being able to care for the baby...but who reallly knows.

Anyway, the grandmother called the mother today and told her that the baby was very ill and she would have to come bring him to the clinic. He had lost several pounds since his last visit and looked visibly small for a child his age. Worse than that though was that he couldn't close his eyes because he was too dehydrated to produce tears and his eyeballs had developed a white film over them. He was too weak to cry or even really move. His neck was stiff, but his limbs were floppy -- not good. Definitely could be meningitis, encephalitis or various causes of sepsis. He perked up quite a bit once we loaded him with IV fluids. He then was transferred to the hospital...I hope he makes it. Will hopefully get to check in on him I go to the hospital with one of the docs on Thursday. Fingers crossed.

Neonatal HSV, Verruca Plantis and Epidermolysis Bullosa - oh my!

Today was our first day in clinic. It was very nice to go out our door and walk 100 feet to work. I could get used to this commute! Kate and I were each paired with a doctor and saw patients from about 8am - 5pm. There were 4 doctors working today who saw over 100 patients total. It was a busy day not only because all of our patients have HIV, but also because at least 10 of them were REALLY sick -- I think more than 5 ended up getting admitted to the government hospital in Mbabane. The little emergency/urgent care room was overflowing most of the day. If you think your Monday clinic days are busy...you should check out this place.

The first patient I saw with the doctor I was working with had a rip roaring case of pneumonia and was breathing 60+ times a minute - that's a lot for a 10 year old who probably breaths 15 times per minute usually. Her family lives 2 hours away and started their trip at 5am to get her to the Baylor clinic. She was so weak that she couldn't walk. And that was just the beginning...

Kate saw a 10 day old baby with HSV (herpes simplex virus). She had tight, raised vesicles all over her forehead, around her eyes and one in her mouth. She most likely got it from her mom when she passed through the birth canal and it's possible that it could go everywhere in her body -- bad news.

I saw one of the leaders of the teen club, which is held once a month for teens living with HIV. He is usually very smiley but today was feeling badly. It was an upper respiratory/sore throat type deal so probably just your run-of-the-mill bronchitis or mononucleosis case. He has been on ARVs (anti-retroviral drugs) for years and has a relatively strong immune system, so this was just like a primary care doctor visit for him. But...he has verruca plantis (flat warts) all over his face, especially around his mouth. It is caused by an HPV virus, and the reason we don't all walk around with it is that most of us have fully functional immune systems. His constant low-level immune suppression allow this virus to stick around and cause what looks like a white-ish, flat rash.

Kate and I both saw these two ADORABLE kids - one 3 and the other 5 years old - with what we think is Epidermolysis Bullosa on the soles of their little feet. It is a blistering disease with a genetic component which gets worse with trauma - a.k.a. little kids running around barefoot. I gave the 5 year old a book and she read it to her little brother in a combination of English and Siswati (so cute!).

Here is what it looks like on light-colored skin. We didn't think it was kosher to start snapping pictures on our first day...but maybe once we get to know some of the patients and families.

So, all and all a very busy and interesting first day. I'm excited for a very infectious disease filled month! :)

Pictures of the trip & day 1

Getting ready for the long haul in the Atlanta airport:

Welcome to Swaziland:

 

Our humble abode (living room, kitchen, & Carter's bedroom):

No, we haven't used the TV (tried for the sake of some noise but couldn't figure it out)

Yes, we have used the kitchen - spaghetti for our first dinner

Carter liked the orange bedspread the best

The Baylor Center of Excellence / Clinic

Not complete without a dedication from the King

Swaziland activity number 1: walk/hike to "the Pinnacle" (a trek pioneered by our classmate's brother who worked here as a pediatrician a year or two ago....though he ran it which is crazy!)

Local guy who wanted his picture taken

The view along the way

Finally made it to the top of "the pinnacle"

Pictures above courtesy of the one and only Carter Denny....here are one or two more that I thought were worth including from the day: 

The road/path ahead as we walked (periodically passed by trucks or motorbikes - one guy actually came back to check on us because he passed us in both directions & wanted to make sure we were okay and not stranded......or he just wanted to come find out who those 4 women were)

Not quite at the end of the journey but at the last big outcropping of rocks was this one - just like a nose!

And one last picture, courtesy of Carter again, is a shout-out for the Denny family...did y'all know that your family is (apparently) responsible for the best creamed cheese mushrooms in Swaziland?

Swaziland at last

Greetings everyone - just wanted to post a quick update that we are safe & secure in Swaziland.  We will attempt to post pictures a bit later (maybe even tonight after dinner), but all is well at our little cottage home for the next month.  We are staying on the clinic/Baylor Center of Excellence property inside a massive gate with a 24 hour security guard.  We got unpacked today, went on a long walk/hike with Stephanie (our supervising physician) and another visiting pediatrics resident, & then we bought groceries. 

After these quick email updates at the clinic building, we will walk back over to our cottage (just across the playground) to make dinner & have a go at uploading some pictures.  The internet connection on my little computer is a little bit spotty depending on where I am seated (currently using it in the clinic lobby while Carter is upstairs on one of the clinic computers), but we're told that bedroom closest to the clinic usually gets reasonable access to the web....so we'll give it a try.

Oh, and I promise Carter will post some too soon.....I've just happened to be on my little computer more on the trip than has she....and she's probably been better about sending emails to folks so far too. 

Are you a doctor?

Do you ever wonder whether the security people actually watch the monitor as your carry-on luggage goes through the scanner?  Well, in Johannesburg they apparently do....and they don't care about what size your shampoo is or how full your water bottle is.....instead, they key-in on the stethoscope. 

That's right, medical vignette number one of this trip resulted because the security lady saw the stethoscope show up when her backpack was scanned.  Then, after confirming to whom the bag belonged, she asked if we were doctors.  I believe "yes" was the simplest answer at the time though I don't really recall exactly how it was explained.  Instead of asking what we were doing here, where we were going, etc, she wanted to know what caused dizziness.

It's a good thing Carter wasn't feeling super-talkative because asking a budding neurologist about dizziness could open up a book of causes.....in fact, I'm sure there are (several) books on that topic alone.  Unphased when Carter gave her standard answer of dehydration (which very often is the case of folks' dizziness), the security lady asked if that would even cause dizziness at night in bed.  Really, it quite possibly could - and she probably doesn't drink enough water, but in order to calm her a little further we explained very quickly about the crystals of the inner ear & how they float in fluid in the ear.  If they get moved out of their normal place, dizziness can result.  So then we explained a brief maneuver she could try at home to reposition the crystals - and Carter imitated said maneuver on one of the security tables (without actually lying down - which is probably good because who knows what security would have thought about that!).

In any case, that's medical vignette number one....I imagine that a good number will follow.  In the meantime, we're in the airport in Johannesburg waiting for our flight to Swaziland in an hour or so.  We will update again once we're settled (hopefully tonight but perhaps tomorrow).

Hope everyone back home is enjoying a nice weekend!

Stop 1 complete

Just a quick note to anyone following back home, we made it safely to Johannesburg this evening.

Our flight left Atlanta at 7pm local time and we wound up here about 4pm local time....quite the flight.  During the boarding process I was sure that I would need something to help me relax for the 15 hours, but it actually went by very reasonably.  We had personal tv/movie devices at each seat which kept us entertained (as well as the pre-K kids behind us....thankfully!), so the flight wasn't actually so bad.  2 movies, 1 book, 2 meals, & 6-7 hours of sleep and continent number 5 is checked off my list.

We'll get a little R&R time now, freshen up from the long travels, & get dinner here in the hotel.  After a good night's sleep, we'll be back at the airport around 8 in the morning to head up to Swaziland. 

No crazy or particularly funny stories yet, but I'm sure they'll come.

Let the adventure begin...

Our trip is finally here!  Time has flown by, today is the day....we start our travels in just a few short hours from New Orleans to Atlanta, and then Atlanta right into Johannesburg (South Africa).  That last one will be a monster of a flight (15 hours)!  We'll spend the night in Johannesburg & get on a plan the next morning for Swaziland.  We are actually anticipating meeting our supervising physician on that flight as she will be returning to the clinic from a conference in Libya.  We will likely also be greeted on arrival by our Swaziland-experts, Mac & Nancy, who are graciously going to be sure we see the best of their country when we have free time away from the clinic.

We will most likely be updating the blog a few times a week between the both of us, so check back as often as you wish.  Pictures will also hopefully be forthcoming but probably a little less rapidly than the text.

Oh! And the other big news, yesterday was Match Day.  For those of you unfamiliar with that, it is the day where all graduating medical students across the country find out where they will be doing their residency training for the next few years.  Carter & I will both be sticking around New Orleans for a little longer.  She for 1 year of internal medicine before going off to Washington DC to complete her training in neurology at Georgetown, and I for 3 years of training here at Tulane in internal medicine.  It will be an exciting time!