Sunday, October 29, 2006


One million calories. Two dollars. Quite tasty. Travel at least a thousand miles to visit me, and I'll buy. -Ryan Posted by Picasa


Thursday, October 26, 2006

Collision course - A training day

“Look out, Sister Mamba!” one of the nurses shouted.

I had never hit a nun in the head with a chair, and was at dire risk of ruining my perfect record. We were trying to fit two dozen human bodies in a room designed for a half dozen, and we were short on chairs. To move furniture in the crowded room, I had to hold it above my head and above the veiled head of one particular elderly, paradoxically-named, surprisingly tall nun.

I am not entirely sure of what I was daydreaming about at the time, only that I was daydreaming. I remember noticing the view from the training room, and how it reminded me of the western North Carolina except all of the pines were planted by a timber company for harvest. I remember seeing a photo of the king on the conference room wall and wondering why he had three red feathers in his hair rather than two, four, or some other number. I may have been thinking about standing outside our clinic the previous afternoon and watching two toddlers chasing each other through the grass, giggling. The one in the lead was carrying a pink backpack over her head in what seemed a game of keep-away. I had refilled her HIV meds the week prior, and had wondered if they were in there, jostling about.

Regardless of what was distracting me, the Sister wasn’t exactly paying adequate attention either. She was talking to her coworker while walking backward toward the corner where I was shuffling steel furniture. Walking blindly in a crowded room during remodeling was risky behavior, especially for a church lady.

Still, I was definitely going to receive all blame if a collision occurred, my not being a nun and all. Knowing this, I executed a quick pivot and awkward but heroic hop, and the collision was averted. More importantly, my soul narrowly dodged eternal hell-fire yet again.

With Sister Mamba and the rest of the group safely seated, we started the day. After a brief review of the previous day, I began the next segment, a two-hour behemoth of a lecture on opportunistic infections (OIs).

I looked out over the faces of the 24 nurses and began my “brief” overview of the diseases that kill their HIV positive patients.

Though the nurses could not fast forward through my two-hour lecture, we can.

Here we go.

“HIV does not kill patients; OI’s kill patients” >>> Tuberclosis >>> Pneumocystis carinii (Pneumocystis jiroveci) >>> Lymphocytic interstitial pneumonitis >>> Candida albicans >>> Varicella zoster virus >>> HHV-8 (Kaposi’s sarcoma) >>> Cryptosporidium parvum >>> Cytomegalovirus >>> Mycobacterium avium-intracellulare complex >>> Toxoplasma gondii >>>Cryptococcus neoformans >>> “Let me wrap up with immune reconstitution syndrome, where your patients appear worse as their immune systems recover after starting ARVs.” >>> “Remember: prevention of OI’s involves careful treatment of HIV, good hand-washing, cooking food, boiling water, etc.” >>> “Any questions?”

One of the nurses in the back raised her hand.

“What if we don’t have running water?”

“Well,” I said, “that can be a challenge. When patients don’t have access to running water, I usually…”

Her hand went up again.

“…I mean if we don’t have running water in the clinic.”

“Well…um…” I had no idea how to answer the question, so I answered with a question.

“How many of you do not have running water in your clinics?”

Around a third of the hands went up.

One of the participants not raising her hand said, “We have water sometimes.”

“Okay. Raise your hand if you don’t have a reliable water supply in your clinics.”

Three quarters up.

“Damn,” I thought, realizing that I would be rotating through many of these clinics in the year(s) ahead.

As a group, we brainstormed solutions to this problem. Water tanks, homemade sanitizing hand gel, digging additional bore holes, etc.

“Any other questions?” I asked, afraid of what might be divulged. Hearing none, I quickly adjourned my portion of the morning.


One of my colleagues called HIV in Swaziland “an apocalypse.” Indeed, the numbers paint a frightening picture. Projections into the years ahead are scarier still, with concerns that countries like Swaziland could actually someday require repopulation.

How do you counter an apocalyptic pandemic without running water?

Later in the workshop, we discovered that most of the clinics in Swaziland also have no laboratory, and that all have very limited access to medicines, with long, unpredictable interruptions in the supply of those they do have.

We did not ask the nurses their salaries, but it is safe to say that few Swazi nurses are able to save enough to buy a car.

I wonder how these nurses feel when they walk into their own clinic and are greeted by an overflowing waiting room. In that clinic, they stand alone against an incessant flood of disease and need, at times without even a trickle of water from the sink.

When I picture this, the typical workday of a rural Swazi nurse, the word ‘underdog’ seems an understatement.

Yet, somehow, they persevere. They preserve hope.

On the fourth and final day of our training, we asked the nurses to divide into small groups and discuss the challenges faced by their individual clinics, as well as potential solutions. After doing this, they presented their ideas, and training certificates were distributed.

As the nurses stowed their diplomas and prepared to leave the cramped conference room and board the even-more-cramped public minivan that would return them to their rural clinics, Sister Mamba raised her hand.

The eyes of the room converged on her white gown. The sister had been quiet during the training sessions and the nurses were curious to hear what she had to say.

She stood.

“HIV is the challenge that will define our generation,” she said. “Our generation’s challenge is that we have much work to do. We cannot only describe the problems. We must return to our clinics and work to solve the problems. We must.”

She sat.

In the room, there was silence.

More silence.

Still more.

…probably 15 seconds total.


Sister Mamba suddenly stood again.

“That was my conclusion and it need not be challenged.”

She sat, chin held high.

The nurses in the room smiled a collective smile, and then applauded. I smiled and clapped along with them, glad I had not hit Sister Mamba in the head with a steel chair.


Monday, October 16, 2006

Teaching pathology - A training day

Teaching pathology: a training day

“How many here have done HIV trainings before?” Dr. Delouis asked. About three-quarters of the 28 community-based nurses in the room raised their hands.

“How about pediatric HIV?”

All hands sank.

“Okay,” Dr. Terlonge said. (I believe this response was short for, “Okay, well, at least we are in the right spot.”)

‘We’ were a group of four American-trained doctors. Three pediatricians and one preventative medicine specialist. We were from San Francisco, New York, New York, and Denison, respectively. That makes three city slickers and yours truly.

We were about to begin a 4 day pediatric HIV training course at the Piggs Peak Government Hospital, approximately one hour’s drive north of Mbabane, Swaziland. Nearly all nurses from the hospital’s catchment area were in attendance.

We were there because, as reflected by Dr Delouis’s informal show of hands, it has been the tendency of developing world HIV programs to focus on adults. They are, after all, the productive population that works and pays taxes. They are also the re-productive population that has sex.

Dr. Delouis explained that, as pediatricians, we were there to introduce them to HIV in kids, beginning with the epidemiology and pathophysiology of pediatric HIV, followed by diagnosis, care for the HIV positive pediatric patient, nutrition in HIV, prevention of maternal to child transmission, etc.

After Delouis spent an hour reviewing the magnitude of Swaziland’s epidemic (summary: very large in magnitude), it was my turn to speak. I was to discuss the pathophysiology of HIV in children (physiology being how HIV behaves and replicates; pathology being how it messes things up).

Physiology and patology talks can be quite boring, so I had been thinking about strategies to spin the topic to the audience in such a way that it seems more interesting.

I needed a hook, if you will.

My father’s name is Dr. Chuck Phelps. He is an avid fisherman, and he knows hooks well. He grew up near the lake with the best striped bass (or “striper”) fishing in the world (or at least I have been told this). I grew up there too. It is a lake called Lake Texoma, and it is called this because it was formed in 1942 when the Red River dividing Texas and Oklahoma was dammed.

For every striped bass in Lake Texoma, I estimate that there are at least three types of hooks that have been designed to get these fish from the water to the boat. My father knows them all. He knows when to use them (dawn, dusk, deep water, shallow water, northerly wind, southerly wind, and so on and so forth). He knows how to use them (reel in slow, reel in fast, make the lure splash, make it sway, make it dance, jiggle, sink, float, pop, slither, juke, bounce, slide, meander, pause, surge, pivot, shimmy, spin, roll over, play dead and so on and so forth). He know where to use them (near the dam, near the Lowe's Highport islands, near Eisenhower Marina, on the rocky Texas shore, on the sandy Oklahoma shore, and so on and so forth).

As far as the ‘why’, my father fishes because he likes spending time outdoors. He fishes with me because he likes spending time with his eldest son. He likes sharing his knowledge of the lake he grew up on. He likes to take fish home and fry them with potatoes and hushpuppies. He likes to sit down with his wife and three kids and share the fried striper he caught and prepared.

My father fishes because he likes to honor and relive the memories of doing the same with his father, my grandfather, who I never had the privilege of meeting. His name was Dr. Ray Phelps, and he was north-central Texas’ first pathologist.

He moved there because he liked the lake, and he wanted his kids to grow up in Denison, Texas. He moved there because there was no pathology department in the local hospital, and therefore no mechanism to routinely examine disease on a microscopic level, the level at which all disease operates. As Dr. Ray was an expert on the microscopic workings of disease, he received a warm welcome in Texomaland.

I didn’t have the opportunity to ask Ray why he become a pathologist, but I imagine he was interested (as I am) in how disease meddles with normal human physiology, how it interrupts the health and integrity of the human body, one tiny cell at a time. I wonder if Dr. Ray Phelps was moved (as I am) by the pain that these tiny pathologic malfunctions can inflict on a previously healthy human being, no matter how young. I wonder if somehow learning how all of the malfunctions look under the microscope offers some comfort that sick tissues might someday regain function.

It was time to start the lecture.

Still, no hook was coming to mind.

My first powerpoint slide was a photo of my extended family on the stuffed bucking bull in Ft. Worth, Texas’ “Billy Bobs”, the self-proclaimed largest honkey-tonk in the world. The photo, as shown, was taken on my recently elapsed 31st birthday.

Posted by Picasa
“What does this make you think of?” I asked.

“Texas!” one of the participants shouted.

San Francisco has its Golden Gate. NYC has the Statue of Liberty. Texas has livestock and more swagger than you can fit in a ten-gallon hat. Eat your core out, Big Apple.

I explained to my audience that the topic I was about to cover had the potential to get a bit dry, and that I wanted to brainstorm with them about how to make it as interesting as possible.

I briefly reviewed my father’s love for fishing, and I brought up the idea of the hook.

“What would be the perfect hook?”

Whispering. More whispering

“Chocolate!” one of the participants proclaimed.

There is a particular chocolate here called “Tex”. It is basically like an oversized Kit Kat. There was a grocery store across the street where they were on special.

“Tex bars? It’s a deal.”

I divided the group into teams and asked them to choose team names.

They chose Team Texas vs. Team New York.

I kid you not.

I then explained that I would ask multiple quiz-type questions throughout my presentation. The team answering the most questions correctly would win Tex bars.

I started with a brief recap of the previous epidemiology lecture. I reminded them that nearly half of pregnant women in Swaziland are HIV positive.

“Do you remember the number?”

“42.6%!” one of the nurses said. Score 1-0, Team New York in the lead.


I reminded them that, without treatment, nearly half of HIV positive pregnant women pass the infection to their newborn child.

“What percentage?”

“About 40%!” Score 1-1.

I told them that HIV was retrovirus, meaning…

“It contains RNA!” 2-1

It is also a lentivirus, meaning…

“It is slow!” 2-2

“Exactly. This means that it lets its host live for long enough to infect others. As a
matter of fact, usually the infectious person has no idea that he or she is infected, for there are initially very few symptoms, and an individual can feel quite well while the virus slowly percolates, becoming stronger and stronger, like the coffee that awaits you as soon as we finish the lecture.”

I could hear the faint clicking of the tea-time percolator on the other side of the conference room door.

I continued to tell them how HIV thinks and acts. I told them how it enters cells, replicates, and then leaves to infect other cells. I told them how HIV destroys the CD4 cells that normally protect the human organism from infection.

They knew much of this. The score was 12 all.

I went into more and more detail and asked more difficult questions. When I ran out of powerpoint slides and difficult questions, the score was tied at 16-16.

I thanked them for being one of the more engaged, energetic audiences I had met (for indeed they were), and then assumed the more casual posture that one assumes to demonstrate that a lecture is finished.

“What about the chocolate?”

“But it was a tie.”

“Let’s have a tie-breaker!”

“Okay. A bonus question.”

I put up the photo of my family, and asked them to point out which one was my father.

They entire room exploded, with all participants pointing to the tall, wide-eyed man with a ten-gallon hat and the big grin.

“What is his name?”

“Chuck!” in unison.

His favorite lake and fish

“Lake Texas-Omaha! Striped sea bass!”

“Close enough.”

My grandfather’s name and profession?

“Dr. Ray! Pathologist!”

Still more or less a draw.

“We will just have to get enough for everybody to have one,” I said.

We adjourned for tea, coffee, Tex bars, and miniature tuna sandwiches.

I have been fishing with my father several hundred times. The last ocassion was just before moving to Africa. We left Eisenhower Marina when the sun was about a finger’s width above the western skyline, and we began to motor about in search of promising waters. The army of pied lures rattled in the three mega-tackle boxes at my feet, the water was glassy and reflected the late day’s light, similar in shimmer and color to coals beneath a dying fire. My father’s face wore an expression of determination, relaxation, and contentment. The horizon undulated as the boat hovered over the broad waves of the broadest stretch of the Red River, so named for the region’s crimson, iron-rich soil. The temperature was such that the moving air neither cooled nor warmed the skin as it passed.

There were no casts that evening. No lure left the boat, and no striped bass became fried Phelps-food. We just toured the spots where the fish might be, looking for splashes, birds, telling wind patterns. Finding none, my father and I spent the last hour of that day simply moving over glowing water at 35-40mph.

I have been fishing with my father several hundred times. No fishing trip has ever come close to that last one.

I bet it would have made my grandfather, Dr. Ray Phelps, proud to see his son and grandson that night, gliding over Lake Texoma, where he once lived.


Weekend in Mozambique

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Tuesday, October 03, 2006

Props to Africa - A situation comedy

The day before yesterday, it was my running shorts. One glance at me leaving work to jog home and the clinic nurses and translators burst into synchronous laughter.

Yesterday, it was my pronunciation of the SiSwati phrase “Sanibonani, S’Celile?” ("How are you, S’Celile?") Apparently my pronunciation needs some work.

I like being laughed at. It speaks volumes about who I appear to be in the eyes of others, and no ex-patriot is going to play a meaningful role in Africa or anywhere else for that matter unless he understands how silly he sometimes seems.

Being laughed at also assures me that those laughing are comfortable letting me in on the joke, the joke being an unwitting me. If a person is looking you in the eye while holding their sides as they shake with laughter, it bodes well for your working relationship.

At least this is what I tell myself.

Still the question remains: Why am I such an amusing spectacle here in Swaziland?

In the two instances above, I came up with the following: Regarding jogging, it must have to do with my willingness to running around in skimpy clothes for no particular reason in spite of the fact that I have a working automobile. (Combined, perhaps, with the blinding pallor of my sun-naïve legs.)

Regarding my blundering the local language, I attribute the laughter to my sloppy delivery of over-enunciated-but-still-mispronounced syllables coupled with the poorly-timed flicks of my untrained tongue in a feeble attempt to create the half-click-half-kissing noise that is woven into my colleague’s name—“S’Celile”. (Pronounced sss—kiss-like sound—eh—lee—lay.)

The kiss sound is actually less like a kiss and more like the sound that a wayward cowboy would make to get his well-trained horse to speed up without using his spurs.

You get the idea.

In a nutshell, Ryan in Swaziland seems analogous to one of those slightly outdated prop comedians (Gallagher, Carrot Top, and the like) who take something ordinary and use it out of context so that it is funny…or sort of funny…or simply annoying.

Of course, unlike yours truly, they do this intentionally and they receive remuneration for their efforts.

In my case, though I am ordinary by American standards, I am most certainly out-of-context here, and therefore my Swazi audience finds me funny or sort of funny or annoying from time to time.

Anyway, this is my working hypothesis. It is not a good or testable hypothesis, nor does it matter much either way.

Allow me to move on to a related topic that does matter.

The “developed world” has examined Africa for many years, and there has been little laughter. We observe from afar with the expectation of seeing darkness, disease, and despair, and so we see them.

Darkness, disease and despair make miserable punch lines.

Some observers do laugh at Africa. They seek opportunities to make derogatory, comparative statements emphasizing Africa’s deficiencies and then they chuckle sarcastically. Such sarcasm is not funny, and these chuckles are laced with ignorance and guilt, inspired by misplaced and heartless pride.

It makes me angry.

Let me tell you about Africa's darkness, disease, and despair from my vantage point.

The nights can get quite dark, darker still when the electricity goes out. (Most of Swaziland has no electricity to lose.) Having recently spent some time in darkness, I found that I prefer dim candlelight to that from a bleaching white bulb, and I have seldom seen brighter stars than those during a blackout.

There is much disease here, but there is also a growing understanding that these diseases can be treated. In all places, sickness can undermine a dignified life, and even diminish one’s will to live. Epidemics and fatalism are close traveling companions. In spite of this, Swaziland’s inhabitants love life, even when surrounded by or facing death. They want nothing more than to live long and be healthy, and I predict that they will have more and more opportunity to do both in the years ahead.

As for despair, it exists here, as it does everywhere. This is, after all, a country where a day’s work earns you an average of 2-3 dollars, necessities are often lacking, and luxuries are essentially absent. Still, I have yet to pass a family on the street and not be greeted. I have yet to shake a hand without it being coupled by a smile and a respectful sideways glance. I have yet to pay someone a compliment and not have it answered by a careful bow. The situation here is difficult, but the people respond with grace and resilience.

Within the context of the “developed world,” Africa may seem a dismal, desperate place. At least that is the story that is told. Hapless despair, I suppose, makes for a marketable human interest piece, and is certainly a sound if not cynical approach to fundraising.

I prefer to tell a different type of story, in which determined, benevolent people face adversity with endurance and a good sense of humor. These stories, I feel, should be the first ones told, for they are stories of hope.

Here is a working hypothesis for you, and I believe this one has been tested: Hope perpetuates itself, and hope in perpetuity has transformational power.

So, if you want to tell me a story about Africa, give me one where the protagonists laugh a lot, even if they are laughing at me. Posted by Picasa


Monday, October 02, 2006

Mountain oysters

The clinic kitchen is where we, the clinic staff, often have our morning tea and eat our lunch. It is a nice place to sit and get to know your co-workers better.

Last week, there were a couple of translators having pumpkin with their lunch.

Pumpkin flesh, for those who have not tried it, is very tasty, sort of yam-like in flavor and color, but less sweet and more meaty.

I explained to the two pumpkin-eaters that pumpkin was not part of a typical U.S. diet.

“Really?” they said, not quite in unison, with eyebrows raised.

Then I explained that we only ate the pumpkin seeds, baked and salted, and that we usually did this after carving out the pumpkin so that we can put a candle in it to make it look scary for our holiday where children dress up in costumes and ask for candy.

“I have seen Halloween in the movies,” one translator said.

I continued. “We do not eat the pumpkin flesh itself, unless baked into a sweet pie.”

“A sweet pie?”

Most pies here are savory, and none contain gourds, as far as I know.

“Do you eat grasshoppers?” one of the ladies asked in a thinly-veiled attempt to one-up sweet pumpkin pie.


“Me either, but they do in the country. Very good protein. We should include it in our nutrition counseling.”

Not to be outdone, I told them about the “turducken”.

“You eat a duck stuffed inside a turkey stuffed inside a chicken?”

“Not exactly in that order,” I said. I told them it was a nice treat for anyone who likes to eat meat. Swazi’s, in general, love meat, though it is expensive and often hard to get.

I told them it would probably work with ostrich and they should start an osturducken business.

“Do you eat caterpillars?”

I was not sure that caterpillars one-upped turducken, but I gave her the benefit of the doubt, especially when she reached into her bag and showed me what looked like pimpled fava beans.

On closer examination, I could see that they were indeed caterpillars. They smelled like caramel-coated almonds with a hint of summertime St. Augustine grass a few hours after mowing.

“I have never eaten caterpillars,” I responded.

"Me either, but they do in the country. This bag was given to me by a patient. Good protein. I am going to show the nutritionist."

And so the dialogue continued. We covered tripe, giblets, wild dove, oxtail, squirrel, snails, frogs, impala, sushi, warthog, chicken heart and other animal products. (Swazi’s, on the whole, love meat.) For you vegetarian readers, vanilla coke, sour mealy meal, and tofu were also mentioned.

The discussion had become a bit more competitive, with other Swazis joining in. The kitchen was getting crowded.

I was outnumbered and outwitted, but still determined to win. This determination was partially inspired by my innate competitive spirit, but there was more than pride at stake here.

You see, over the years, I have grown tired of “Westerners” tendency to sensationalize the dietary habits of the rest of the world, and I wanted to prove that our foods are at least as bizarre and grotesque as the next guy’s.

If we were keeping actual score, I would have been down by at least a few points, and time was running out. So, as my dining companions finished the last of their pumpkin, I threw the Hail Mary.

“Have you ever eaten a mountain oyster?” I asked.

“A mountain oyster? What is that?”

“It is the one with a shell that grows in the mud,” another said.

“Nope,” I said.

I thought briefly of an evening spent shucking and eating oysters directly out of Tomales Bay while camping with my family on the northern California coast. I did the same with my good friend Heath a month later, with a side of a couple Sierra Nevada beers.

Beers and oysters. Family and friends. How far away they sometimes seem.

“A mountain oyster is also called a calf fry.”

“A what?”

“A calf fry.”

“Fried calf?”

“Not exactly.” I paused until the anticipation grew more palpable, then told them a story about how these were my father’s favorite delicacy, if not a close second behind fresh oysters with Tabasco. (They do have Tabasco here, thank the heavens.) I told them how he fed mountain oysters to my in-laws without telling them what they were.

“Well, what are they?” “Yeah, what are oysters from the mountains?”

I told them that the mountains of Swaziland was home to many of these oysters.

The tension mounted.

Finally, I told them.

“Fried bull testicles?”

The group giggled, exchanging knowing glances.

“Dr. Ryan, Swazi’s prefer them roasted or stewed.”


“Well, I’ll have to tell my dad that I am not as far from home as I thought.”

My nostalgia lifted slightly, though from now on I plan to carefully identify all roasted and stewed meats prior to consumption.

I learned this the hard way. I was in grade school. My father served me a fried morsel, and told me it was fish. Posted by Picasa


Sunday, October 01, 2006

Sunday brunch

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