Thoughts & Notes about Medicine in Swaziland

We have safely returned to New Orleans & started on the all of the paperwork for graduation & residency that has been patiently awaiting us.  I do, however, have a small list of thoughts and topics on which I wanted to comment from our time working in Swaziland.

To start, just some general information about HIV in Swaziland gleaned from conversations with the doctors.  One interesting part of the epidemic in Swaziland, and in many ways Sub-Saharan Africa overall, is that it does not have the same drivers as some of the other infamous HIV epidemics.  As I studied for public health coursework, the HIV in Thailand is driven by commercial sex workers while much of the HIV in Vietnam is a result of intravenous drug use.  Those are two common drivers of HIV epidemics everywhere.  In Swaziland, though, there is not such a clear cause for the extensive spread of HIV.  The major contributors to the epidemic in Swaziland seem to be two things: to start, working way from home.  Many men travel for their employment - go to South Africa to work in the mines or drive trucks.  The time they spend away from their homes and their wives does not mean that they're not sexually active at that time, however, and whether from infidelity or using prostitutes, these men subsequently expose their wives to a whole host of sexually-transmitted infections, potentially including HIV.  A second thing in Swaziland that perhaps has historically (or currently) expanded upon this aspect of the epidemic is polygamy, which is legal & in many cases a cultural norm in Swaziland (where the King has several wives).  Although polygamy itself will not likely send HIV rampant through a population, there will be more spread of infections when a husband comes back from being away & unfaithful to not just one wife but several.  The second major apparent driver in the Swaziland epidemic is vertical transmission, from mother-to-child.  We learned that 42% of women seeking antenatal care in Swaziland are HIV positive....and one must consider who that percentage may be missing.  It does not take into account all the women who may not seek antenatal care (and one could perhaps argue that a higher percentage of those women may be infected) or women who choose not to test themselves for HIV, whether before or during pregnancy.  It is the general opinion of many of the physicians and other healthcare workers that the only way to make a strong and successful impact on the prevalence & incidence of HIV in Swaziland is by reducing/preventing the mother-to-child-transmission of HIV.

In any part of medicine, there are always old-wives tales & other lore surrounding diseases, treatments, medicines, & so forth.  I always find it interesting to hear the questions that arise in regards to such topics.....and the concerns seem to be most off-the-wall (to someone who is scientifically trained to any extent) when they are in regards to HIV, sexually-transmitted infections, & pregnancy (perhaps because the topics are somewhat taboo and go un-discussed in many households).  During one of our weeks in Swaziland, Carter & I sat in on a nurses' training designed to teach about HIV and providing anti-retroviral drugs to the patients at the non-Baylor clinic sites.  At the end of the first day when the floor was opened up for questions, one of the nurses asked about the truth behind or explanation for the lore (which apparently circulates in some circles in Swaziland) that the ARVs to treat HIV increase sexual appetite/desire.  The matter-of-factness with which the nurse asked the question almost made the whole thing funnier (though in a sad way I suppose) to me on some level....the physicians who were leading the training session, however, gave a very reasonable explanation without belittling the nurse for expressing concern for this view that her patients (and/or patients' parents) often hold.  The doctor explained that the antiretrovirals make patients feel better & less sickly, and thus it's not entirely unreasonable that the would then have more energy to do things that otherwise healthy individuals would also be doing. 

Hopefully from the things that Carter & I have posted on the blog, you will have gotten the impression that we had a great experience& really did get to work in a great environment that Baylor has been able to create in its clinics.  There were, however, little things that affected the clinics if not the entire country that to those of us practicing in healthcare in a Western nation would find more than a little crazy.  For instance, we often hear about their being blood shortages in the States....and many of us have probably gotten the phone calls or mailings requesting that we make blood donations to help replenish the supplies.  Earlier this year (before Carter & I arrived) there was NO blood for transfusions in Swaziland....none at all, even for emergencies and children with hemoglobin values less than 5 or 6 (or lower).  We heard of a couple very sick patients that the doctors worried so much about that they started to take stock of which physicians had what blood-types in case they felt like the only way to get blood was to donate it themselves.  Similarly to the blood shortage (which was somewhat resolved when we arrived as there was blood available), there were essentially no urine dipsticks available in Swaziland when we arrived.  Eventually by the time we left, one of the doctors was able to find some at a private pharmacy/medical supply warehouse - but the government facilities as well as the private facilities had been without the simple test strips to analyze urine.  Instead, if they suspected someone had a reasonably straight-forward urinary tract infection, they simply treated to cover for it & hoped that the symptoms resolved.  The only real study they could do to that extent in the clinic was to look at the urine sample under the microscope, in case there were obviously bacteria or blood cells therein.