Easter weekend, installment #1

We are finally winding down our long-weekend this evening, probably not too much differently than anyone else may be doing - a little laundry, email & internet catch-up, & planning for tomorrow.

Carter & I had another great weekend with Mac & Nancy, tour-guides supreme (as Carter has dubbed them).  Since Swaziland is a very Christian country, the clinic (like many other small businesses) was closed from Good Friday through Easter Monday.  That means we had plenty of time to fill with new adventures....it also means that I would write a small book if I tried to tell our stories in just one post.  So, instead, I'll start it off with just the first day or so.

Mac picked us up Thursday afternoon after he finished his afternoon's errands.  We stopped for ice cream bars & then picked Nancy up from work before heading to their home.  We had a very relaxed & enjoyable dinner on the back patio - grilled chicken, a dish that was essentially grits, tomato sauce, cream, & cheese, & a beautiful salad.  It was fantastic to sit & enjoy the cool & quiet evening.....the biggest excitement came when the frogs started their calls.  When the little frog (which had a huge call) finally showed up, the cameras came out....and then Mac set about searching his yard for other interesting critters we could photograph! I was a willing participant as I'm still playing with the new camera....we ended up with some great pics of a huge praying mantis on a Bird of Paradise blossom as well as the tiny frog.

 

Friday we got up early & hit the road for international excursion #1: Maputo, Mozambique.  We got to the border easily, before too many crowds were there, so our transition was smooth.  Even at the border, the difference between the two countries' infrastructures was starting to be obvious....but we got our visas for Mozambique, & we were on our way.  We crossed at the Goba border point & started down a windy mountain road, which gave us great views of the Mozambican countryside as we headed toward the capital city of Maputo.  The countryside we passed was sprinkled with very small homesteads but little farming.  The country has only recently begun to recover from years of war, and so much of the land is yet to be put back to strong agricultural use.  There are also still areas of the countryside that remain to be de-mined.  As we wound our way into the Maputo area, we passed many guys selling slate tile on the side of the road - intermixed, of course, with the requisite country farm animals (goats, sheep, cows, pigs, etc).

Another thing of note that we passed on our way, near one site for the Mozambican military training/barracks, were the remnants of Russian warcraft - a few tanks and a helicopter that the Russians left behind.  When they all left, however, they did not leave behind either the infrastructure or the support to make any of their tattered machines serviceable again (which might be okay as far as the tanks go) - so they've sat where they were left, grass growing around & rust slowly accumulating.

When we got to Maputo, we drove for a little while in the non-tourist zone as Mac wanted us to also have the chance to see how the average person there lives.  It was much more in-line with the image of a developing country that most folks likely have - small houses/huts that are very near one another with families selling their goods alongside the main roads.  As we turned around to head back towards downtown & the port, we were lucky enough to be selected as one of the vehicles to pull over for the traffic police checkpoint (it seems that having out-of-the-country license plates there is somewhat analagous to having out-of-state plates in small towns across the US).  Although we were doing nothing wrong, the officer was looking for something to find.....so he peered his head in & decided that since Carter & I didn't have our seatbelts buckled at that moment in the backseat, he was going to issue a ticket (nevermind the vans & buses driving past us, overflowing with people - all unbuckled)......so when Mac told him that he didn't have the money for the ticket (which was supposed to be 1 million Mets - $1 US is something like 30 Mets), the traffic cop just asked "well, what do you have?" I don't know how much he ended up with, but it was a fraction of what we actually had, & we drove away without a ticket.

But, enough of that stuff....we made our way into downtown & Mac took us on a driving tour of the sites - the beautiful old train station, the market, a few restaurants & bakeries his family used to own &/or visit.  We stopped at a small restaurant along the coast for brunch & snapped some photos as the tide came slowly in.  We got a short walk on the beach, scaring away a number of ghost crabs, & then headed further into the city to go past the old cathedral, the parliament building, and a few other spots. 

When it came time for lunch, we drove further along the coastline of the city to a restaurant called Costa do Sol - apparently one of the most famous & oldest restaurants in Maputo (if not all of Mozambique).  It managed to stay opened & operating through all of the city's turmoil - and it's still owned by the same family from Greece years ago.

By the time we finished a delicious lunch, fended off a few more folks selling souvenirs, & got back in the car, I had developed a very mild pink sunburn on just one arm (I think since then it has evened out a little however).  Our last stop was a hotel up on the cliff, overlooking the city & harbor.  We snapped a few more pictures, stopped for a cold drink, & then loaded the car back up for our journey home.  The border was again a quick & easy stop (though I did get an indirect proposal from one of the Swazi immigration officers - American green cards are still a hot ticket item apparently).

When we got back late Friday evening, we were lucky enough to find that there was no water at Mac & Nancy's house.....apparently the main pump had gone out.  So we filled sinks & buckets from the tank outside & made tentative plans to all stop by our cottage for showers the next day on our way to South Africa.  We had heard from a friend of Mac & Nancy's that the water pump needed a part from Jo-burg, which they didn't expect to get until Tuesday because of the weekend holiday...yikes!  It turns out, that they were able to get the water running sooner than that (at least as far as we could tell)  because we never had to resort to using our little cottage in Mbabane for showers.

Outreach Clinic in Sithobela

Last Thursday I went with one of the BIPAI (Baylor International Pediatric AIDS Initiative) docs to one of their outreach sites in Sithobela, a very rural town out in the bush about 1.5-2 hours drive from the main Baylor clinic in Mbabane. Kate has been there as well, and we will both likely go back at least once during the next 2 weeks. Sithobela Health Center is comprised of a small clinic building and adjacent hospital, which has somewhat limited services. They have some great doctors and nurses, but very few antibiotics, spotty lab services and only intermittent power. The power went out 4 times on the morning I was there. On the dirt road to Sithobela I saw something very interesting...a cow on a leash! It is certainly not uncommon for cows to be in the road in Swaziland, but this one cow was been lead by a young man on a leash, much like you'd walk a dog. I guess, why not?

When we got to the clinic there were roughly 40-50 people in the hallway outside our little clinic room and spilling out of the building. We saw about 20 patients and their parents with siblings in tow over the course of probably 3 hours. I saw a new diagnosis too -- cutaneous larva migrans in a toddler. The kid has worms that intermittently crawl out of the skin on his left hand. The mama worm is likely laying her eggs underneath his skin, delightful. Luckily it's treatable (with Albendazole)!

Here is a picture of cutaneous larva migrans on the hand of a light-skinned person:

We also saw some very sick patients in the hospital. The first was a teenage girl who just looked very despondent and weak. Apart from being very dehydrated she was suspected to have possible cryptococcal infection...that or a viral meningitis -- neither of which would be good. Then we saw a young mother and her son, who were both admitted with weakness and fevers. After the little tater tot coughed in my face I learned that they both have active TB. Fantastic. N95 masks and true isolation don't really happen in most places that we've been here. I do bring my own mask with me to the hospital, but even then preventing TB exposure here is almost impossible. It is thought that 80% of HIV patients in Swaziland will have concomitant TB in their lifetime. In addition, people are often really close together, making the spread of the mycobacterium very easy. Van taxis (called "kombis") are packed with people and many Swazis have a tendency to stand really close together in public places...especially in queues or waiting rooms. Not to mention that many homes are small with several people sleeping in the same room (while they have fever, nightsweats and cough).

That's all for now! We have many pictures and stories from our long Easter weekend, but it will take some time to put those up. Hope everyone is doing well!

pre-weekend storytime

Greetings everyone....our internet connection has been shaky over the last few days, so don't worry if you have not heard from us.  We're not sure if it's the wireless server or the thunderstorms that have been rolling through intermittently or some combination thereof.  Even now, I could not connect well to the internet inside our cottage, but sitting on the clinic patio, the signal is better than ever.

In any case, we are doing well - have just finished (& Carter is just finishing, returning from on outreach site) our second week of clinic.  I will write more later about some of the cases I have seen & thoughts I have had, but for now just an update & weekend plan & funny story.

Mac will pick us up later this afternoon/evening, & then we will all go pick Nancy up from work.  We don't know exactly what we will do this weekend but are anticipating at least a daytrip to Maputo, in Mozambique - which is supposed to be quite lively, according to the doctors we work with.  We will update the blog with tales & pictures after the long weekend has ended on Monday night.  In the meantime, you may not hear too much from us as internet at Mac & Nancy's is not always very quick either.  We will, however, be back to work in the clinic on Tuesday.

So, now that you've read through the "business" bit of the post, here's your story.....

I was seeing patients today with Stephanie, the physician who is our supervisor here in Swaziland.  A woman (probably late twenties/early thirties though ages are hard to guess accurately here) had brought in her little brother to be tested for HIV and evaluated because she's afraid he has TB (their parents both died a few years ago from multi-drug resistant TB....it will get funny, I promise).  In any case, we were waiting for the boy's chart to pull-up on the computer (I know, an electronic medical record in Africa but not in many parts of New Orleans and the States!) making small talk.  The boy's sister laughed a little, smiling at me, & began to say "You're the first white girl I've seen in Swaziland...."  So immediately I was intrigued....I quickly thought about what I was wearing that day, what I had done between getting them from the waiting room & walking back to the exam room, what I had said (or not said), etc....all in an attempt to guess what she was going to say. 
Well, I should have known....I don't recall her exact words, but the gist of her remark was that I was the first white girl she had seen in Swaziland with an African-esque backside.  In fact, she was so impressed with the fact that my behind and hips were in proportion with the (black) women here that she called & told a friend....and I'm not totally clear, but I think she may have even taken a picture on her phone & sent it to said friend!  And just in case anyone is taking offense for me, you don't need to.....it was not meant to be an insult - the woman actually said that it was a good thing (and then she laughed a little more....though I was laughing with her).  The whole things is so funny to me because it's absolutely true (and pretty much all of the white women I've seen around Swaziland, wherever they may come from, do have pretty flat behinds) - - but also because she had the nerve to say something about it!  I suppose it's because she's close to my own age that she felt comfortable, but it was quite the moment!  Then, of course, when I was leading her & her brother to the next part of the clinic, I was somewhat self-conscious of how my dress swung on my hips when I walked (though she just laughed again in appreciation).

I'm sure there will be many more great moments during our trip, but that one will be hard to beat!  That gal'd fit right in down in New Orleans!!

In any case, I hope everyone has gotten a good little laugh from my story & has a great Easter weekend!

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).