Author's disclaimer

The patient-specific details in the narratives below are altered to protect the patinets' confidentiality. Thank you for reading.
Sincerely, Ryan

Recent BIPAI press

Please see the link below for this week's Time magazine article about BIPAI. The second link will take you to a related video filmed at the Baylor site in Lesotho.

http://www.time.com/time/magazine/article/0,9171,1562960-2,00.html

http://www.time.com/time/video/2006/pediatric_aids_gorman/

Parentless children with nothing to lose

There are around 1,000,000 people living in Swaziland. 500,000 are adults. Up to 200,000 of those adults are infected. Most of those infected are caring for children. 20,000 of those infected need ARVs immediately, or they will soon die of AIDS. The remaining 180,000 adults have an average of around 10 years before they will meet the same fate.

Today, there are 70,000 orphans in Swaziland. In 2010, there will be around 120,000.
120,000 children without adult caregivers.

This is not complicated math, and the dangers of allowing 120,000 parentless, unschooled, unemployed, undernourished, helpless, hopeless children wander a small country are not difficult to calculate either.

In the words of Derek Von Wissel, the Director of Swaziland's National Emergency Response Council on HIV/AIDS (NERCHA), “They will have nothing to lose. They will be rampant. It is a nightmare.”

This is a nightmare we will most certainly want to wake up from. Should we not wake up sooner than 2010?

To do your part, see the following link, or email me for other ideas as to how you might contribute.

www.youngheroes.org.sz/index_home.asp

The deepest cut - A patient encounter

Yesterday, my last patient was a ten year-old boy who came in with a small fraction of the medicine he was supposed to have leftover, suggesting that he took nearly twice the prescribed dose. He came to the visit alone.

The boy, named Patrick, was one of those children who is accustomed to acting like a grown up. He looked at me solemnly, sitting with legs crossed, his school uniform well-kept.

I spoke to Patrick for a while regarding his ARV adherence.

His answers were measured but tentative, as if he felt ashamed of his recent performance. He preferred to say them in SiSwati, though his English was very good.

He told me that his younger siblings (he has many) were playing “doctor” with his medicines, and he thinks that they spilled some. While this explanation was far preferable to the possibility that Patrick was simply taking way too much medicine, I was not sure if he was being entirely honest.

How could he be honest? He was a ten year-old alone in a room with a foreign doctor and unknown translator, no doubt wanting more than anything to escape unwanted judgment and scrutiny, to defend himself, to make me stop asking him questions.

I told him that, when I was ten years old, I never went anywhere alone because I was too scared. I told him that I only spoke one language, and that I could never remember to take my medicine (daily chewable vitamin).

This made him smile faintly.

After speaking with Patrick, I was concerned that he may have actually poured out a few ounces of liquid medicine in an attempt to show us that he had actually been taking them well.

He wanted to be a good patient, but he didn’t understand the dosing. He didn’t understand that poor adherence leads to resistance, which leads to sickness and eventually death. He had recently watched his mother meet this fate, but now was not the time to bring up such things.

With the help of our clinic’s social worker, Nosipho, I contacted the patient’s 26 year-old sister, who lives in a neighboring town to the boy, and asked her to come in. I sat down with her in the clinic and learned even more about Patrick’s circumstances.

The boy’s primary caretaker is his father, who reportedly drinks too much and does not know his son’s HIV status. The father does not know for two reasons: (1) The rest of the family believes that he gave the child HIV during a cutting ritual some years ago. (This is a much less common route of transmission among children when compared to transmission during birth, but still possible.) (2) The patient’s family worries that, if the father finds out, he will get drunk and tell the entire community of the child’s status, leading to stigma and an even more difficult situation.

So, the patient’s fifteen year-old sister (the next oldest in Patrick’s household) had been supervising the dosing and administration of the medicine, a responsibility that she may or may not be qualified for.

Given the patient’s recent adherence record, I was beginning to have my doubts.

After much probing and troubleshooting, we made a plan.

The older sister has a one-room home, and cannot host Patrick. She can, however, check in often to ensure that Patrick is sticking to his regimen, and she can mentor the younger sister until she is comfortable supervising.

Both sisters (the 26 year-old and the 15 year-old) plan to come back to the clinic next week with Patrick in order to review the importance of ARVs, to go over their correct dosing, and to find an appropriate hiding place so that the meds are not mistaken for toys.

If the 15 year-old sister seems up to the task at that time, we will continue the ARVs. If not, we will have to stop Patrick’s medicines.

The risk of toxicity and resistance are too high if he continues to receive faulty doses.

What then? I do not know.

It is a frustrating case.

Related article

The following NY Times article (24 Nov) relates to the entry titled "The deepest cut". Have a look.



"Traditional Ways Spread AIDS in Africa, Experts Say." http://www.nytimes.com/2006/11/21/world/africa/21cameroon.html?hp&ex=1164171600&en=b550b9a2e6a1d128&ei=5094&partner=homepage

What am I up to? (21 November-25 November)

The week has been one of those “steady-as-she-goes” kind of weeks. Similar to last week, I worked in our outpatient clinic (see entries below for more specifics) from Monday through Thursday, and yesterday we had general staff and MD meetings (see below for abridged meeting minutes).

In actuality, I have been doing a lot of behind-the-scenes work in preparation for this weekend’s Thanksgiving dinner, but to no avail.

On that note, if you know how to procure an ostrich in Swaziland, contact me immediately. (Alive or dead is fine.)

Apparently they used to run around wild here, but I cannot find one anywhere, though their painted, preserved eggs clutter every curio shop in Sub-Saharan Africa.

I tell you, fellow Americans (and other highly-valued blog readers), I am shocked at the absence of a Thanksgiving ostrich market in these parts. Shocked.

There are a few big, flightless birds running around the Mlilane Game Reserve a few kilometers from here, but I have zero interest in having my Thanksgiving meal in a Swazi prison.

Less than zero.

It would be a very un-American experience.

What I would not do (besides Swazi jail) to carve and eat ostrich before Thanksgiving weekend ends!

I would settle for guinea fowl (turkey-like, as pictured above) if they were not so gamy and tough.

Oh well, we may have to settle for a gobbler.

Now that I think about it, since there is no football on TV (the pigskin variety, I mean), we might as well eat gobbler to Americanize the experience a bit.

The rumor is that there will be apple pie.

This thankful pilgrim certainly hopes so.

Poisoned – A patient encounter

I recently saw a patient with a platelet count of 12,000. This is less than ten percent of a normal platelet value. HIV sometimes does this, and when it does, the risks of uncontrollable bleeding are significant.

In this case, HIV did this to an adorable 4 week-old baby. When I saw the value, I was worried.

To give you an idea of how worried, let me say this: I think I would personally rather contend with swallowing a teaspoon of rat poison than a platelet count of 12K. (I need to research this further, as rat poison comes in differing strengths.)

In any case, the patient was adorable, but in a perilous condition, and I was worried.

--

Some of you might believe that all month-old babies are “adorable”.

Well, the way I see it, human beings (including you) are wired to perceive this, or else why would we ever want to make more of them?

After all, young infants are loud. They smell. They are forever wriggling as if they can’t get comfortable (which I find unnerving). Above all, they are poor communicators.

I trust you agree with all this.

If not, before you question my potential to some day become a loving father, let me explain.

During pediatric residency, it is frequently your assignment to usher a ward full of infants safely through the night. At some point during your umpteenth sleepless night surrounded by a screeching chorus of someone else’s offspring, you realize that the categorical assumption that babies are “adorable” is false.

This realization is profound, and when it hits you (usually at around 3:30am), your wiring changes, and the change cannot be undone.

The first step after this transformation is simple: because the word “baby” is essentially synonymous with “adorable”, it becomes necessary to refer to them as something else. My favorite four euphemisms were “urchin”, “peanut”, “booger” or “the one in that crib over there”. I used these terms with discretion, of course.

The second step after the renaming the “babies” is the realization that some peanuts are not as attractive as others. Though I will admit that the determination as to which “ones” are adorable and which “ones” are not so adorable is a matter of personal taste, I consider myself quite skilled at judging adorability.

Please do not consider this an affront to your intrinsic loyalty to the urchins, and realize that I am [partly] kidding.

This is just my post-training confession about how some babies are definitely not adorable, ugly even.

I was certainly ugly, for I was 6 weeks premature. I had a head like a toaster. As a matter of fact, if I were to shave my head (I have no plans to), you would likely find that it is still a bit boxy.

Fortunately, my mother and father are wired to find me adorable, and were from the beginning.

--

Speaking of the beginning, my confession, though it may seem a unnecessary aside, is meant to emphasize something I wrote in the second paragraph above:

Four-week-old Nonhlanhla was indeed “adorable”, at least a 9.5 on “Ryan’s 10 Point Scale of Adorability”. (I scored a two at birth, and am still fighting my way up towards three.)

Nonhlanhla was also very well-appearing. Fat, alert, active, making those strange, senseless noises that healthy babies make, squirming for no reason in particular, probably wanting to stool or something.

I picked the baby up to check her muscular tone. It was normal.

--

In pediatrics training, you handle little “babies” often. Picking up tiny human beings is initially anxiety provoking, as you don’t want to drop ‘em, bump ‘em, or do anything at all that might make ‘em cry.

I have almost dropped plenty of babies, usually because they are born slippery and I am the one who has to catch the shiny, writhing (or worse, limp) bundle of slimy joy. Suffice to say obstetricians would make miserable quarterbacks.

However, by the end of my three years of training, I figured out the best grips. Thanks to the stars above and my dexterity, I never once had to hear that unfortunate “thump”.

--
Despite my highly evolved grabbing skills, handling Nonhlanhla made me slightly nervous. Normal platelets are in the hundreds of thousands, meaning that this baby was at least 47 cards short of a full deck (hematologically speaking, of course).

Content that the baby had normal neurological tone, I laid her down gently, and told the parents that the baby was adorable.

(I emphasized that the complement was sincere by pointing out that the baby was actually the most adorable I had seen all month, which the mother seemed to appreciate. The translator was slightly less appreciative, as I had seen her “baby” in the waiting room earlier that morning. I back-pedaled until both mothers were satisfied.)

After completing my exam, I explained that Nonhlanhla needed to start antiretrovirals as soon as possible, because she has thin blood with very few glue cells. I explained to her that HIV was likely the culprit. I told her to be very gentle with the baby, and to come to the clinic immediately if the baby seemed to be acting differently (less active, less pink, less hungry, less alert, less symmetric, etc.), or if Nonhlanhla had bruising or bleeding of any kind.

The baby is coming back early next week, when I plan to review both mom’s and baby’s chext x-rays for signs of TB (mom and baby have been coughing), complete the requisite adherence counseling, and initiate ARV therapy.

I hope the next visit goes well, for Nonhlanhla’s blood will not regain its stickiness as long as HIV is poisoning it.

Standardized testing - Reflections on the mundane

This week, I spent Monday through Thursday seeing patients and reviewing labs.

The “reviewing labs” aspect of my job occupies on average 5-6 hours per week. Initially, these hours of flipping through page after page of number-riddled lab forms and typing the labs into the computer seemed numbingly mundane compared to spending time with the patients themselves.

More recently, I have upgraded the experience from numbingly mundane to somewhat tolerable.

Here is why.

Physicians look over lab numbers in the same way that a mathematics teacher grades papers. However, the grades they assign, rather than reflecting a pupil’s intellectual progress, reflect the complex arithmetic of a struggling human body.

For example:

Question #1: Hgb = 8.2 X

If the body lacks micronutrients, the body is unable to add iron to red blood cells, and as a result they become smaller and fewer. A hemoglobin score below 12 is incorrect, but depending on my mood I sometimes give partial credit, especially if the average size of the RBCs is reasonable (suggesting decent iron stores). If the body reports a hemoglobin less than 10, I mark it wrong. If the value is half that, I call the patient to make sure they are still alive, and ask them to come in for evaluation and treatment of severe anemia.

Question #2 : AST = 290 X

If the body is receiving medicine that is metabolized by the liver, and the liver multiplies its serum transaminases by two or more as a result of the addition of that medicine, I mark it wrong. If the liver does not adjust and subtract those transaminases from the blood when I repeat the test, then the medication at fault must be substituted or discontinued.

Question #3: CD4 count = 290

Every math teacher has a favorite question that always ends up on the test. It is my theory that teachers ask such questions for two primary reasons: (1) To make the student feel good and to bring out his or her best. (2) To make the teacher feel justified in his efforts to educate a room of distracted young people; that is to say, to remind himself that he is indeed an effective teacher.

The CD4 count is my favorite question to ask. It is also my favorite to grade, for the grades almost always keep getting better and better.

HIV infection compromises nearly every normal calculation of the human organism. When the virus is suppressed, the body tutors the immune system, and the body thrives. When unfettered with disease, the body is simply brilliant.

I like CD4 counts because they allow the recovering organism to show off a bit. CD4s also allow me to remind myself that, though challenging at times, what I am doing here works.

--

This past Wednesday, there was a stack of CD4 lab results back from the public laboratory, where all of our bloods are processed. The top form was that for patient #3104. I entered the number into our electronic medical record system and learned that #3104’s name is Busi Dlamini.

Busi is a 9 year old who was started on ARVs shortly after the clinic opened in April, 2006. Her CD4 count was very low at that time, a mere 54.

According to her medical chart, her CD4 count was 134 three months later (July, 2006), and when drawn this week it was 320, demonstrating a nice, steady rise. The medicines were working. Because of this single number, Busi was very likely going to live for many, many years.

I signed my name below the value, documenting that I had reviewed it and entered it into the computer.

--

There are those that want their name in lights.

Then, there are the teachers, who deserve their names in lights, for their vocation determines our children’s future.

Then there is me. I do not have the patience to be a effective teacher. I do not want my name in lights. I am content to have my name next to Busi’s CD4 count of “320”.

Doctor’s Meeting Minutes (DRAFT), 24 Nov 2006

Suppose you were a fly on the wall...

Doctor’s Meeting Minutes (DRAFT), 24 November, 2006
(Respectfully submitted by Ryan. Actionable items in red. Contact me with additions/corrections.)

1) Patient flow log (Delouis)
· Reviewed purpose of log, which we will use for 2-3 days to gather info on pt flow and complexity of visits. Translators to fill out with MD help as needed.
· Also logging lab entry time to measure how many MD-hours being used.
· We are doing both of these logs to improve efficiency and to build argument to hire digitizing staff to protect MD time. Discussion ensued.

2) Outreach updates (Dewey et al.)
· What is going on, in brief? Are folks happy or wanting to rotate?
· Piggs Peak
- Dave and Dan D. in PP, getting to know folks and doing bit of everything.
- There are 5 docs there, but PMTCT strategies are high yield investment opps for our docs (little VCT, with 50% or more HIV+ but poor f/u).
· Shumwula/Lomahasha/Good Shepard (Gretchen and Helga)
- Gretchen and Helga happy to have other docs come with them.
- The perspective from being “out in the field” very valuable.
- Gretchen recommends grant-writing over holidays to try to ensure some inflow, esp. for transport. (UNICEF a “maybe” at this point.)
· Matsangeni Govt Hlth Center (Sach)
- Many challenges, esp. in peds and PMTCT. (Eg: Cotrim/MVTs often not available.)
- Still, have made great strides in short time, building inroads and demonstrating partnership and support.
· Mbabane Govt. Hosp (Nanda)
- This has been Nanda’s site for 3 months, and she sees positive changes with her persistent presence. (Eg: Malnutrition protocol starting to work.)
· COE (Amy, Julia, Eric, Ryan, Johanna, and others):
- All generally happy at COE, but little protected time for other projects.
- Working on pt flow.

3) Protocol committee
· Diarrhea (Helga)
- Reviewed “Diarrhea SOP” draft, derived from Uganda SOP.
- Reviewed zinc, vit A, antimicrobials, and antidiarrheal data, in brief.
- Plan to look over diarrhea SOP and discuss/edit next week.
- Need for water hygiene handout and rehydration SOP.
· Adult ARVs (Eileen)
- AZT vs D4T for adult is a question that freq comes up
- Proposes we shift from D4T to AZT for new ARV pts unless good reason not to
- Also cited 2 recent studies from Uganda and SA (see Eileen for refs)
- Cut-off for anemia in adults <>

You have the wrong hospital - A virtual tour

“You have the wrong hospital.”

These words greeted me the first time I drove up to the gate of Mbabane Government Hospital (MGH).

“The private hospital is across town,” the guard continued.

“No, no, I am a doctor coming to work here in Mbabane, and I want to see the hospital.”

“You are not here for sickness?”

I wasn’t sure how to answer that question. Sickness was certainly involved in my decision to leave the United States, join the Pediatrics AIDS Corps in Swaziland, and find my way to Mbabane’s primary pediatric referral center.

“I am not sick, but will be working with many of the sick children here.”

That was quite some time ago, and I have indeed worked with many of the sick children here. This past week, after nearly three months of working primarily in the outpatient HIV clinic supported by Baylor, I spent a few days at MGH seeing patients alongside the doctors and nurses there.

While it is still fresh on my mind, I wanted to offer you a short, virtual tour.

The pediatric ward of Mbabane Government Hospital is known as “Ward 8”.

Just before you enter this ward, there is a large ORT/Nutrition room to the right, where children spend the day if they need oral rehydration (the T in ORT stands for “therapy”).

Children present to Ward 8 for many reasons, but among the most common is diarrhea, malnutrition or both. This is not an easily-solved problem, considering that children are usually subject to an unsafe water supply and food insecurity for a long time before arriving to Mbabane Government Hospital. Recuperating from a long-term, progressive condition requires time, and it is difficult to ensure that a severely malnourished child gains weight. For this reason, the ORT/Nutrition room is staffed by two very kind nurses to oversee this process. One of these nurses is named Happiness. If you find yourself entering Ward 8, pop in to tell her hello, for she is appropriately named.

As you enter Ward 8, you will notice that it is bisected by a long hallway. There are three large rooms off the hallway to the right, and there are several smaller rooms off to the left. The first door you reach is on the left, and it is the Pediatric Intensive Care Unit (PICU). To those trained in academic centers in the developed world, intensive medicine is defined by supporting fundamental physiologic functions, like, for example, helping a child to sustain dropping blood pressure, maintaining electrolyte balances when the body’s regulation falters, mechanically filling the lungs with air when a child cannot do so on his or her own, or even monitoring and controlling the pressure inside of a child’s skull to prevent brain loss or death after trauma (usually mechanical) to the central nervous system.

In Ward 8, intensive care means something quite different. The 4-5 children in the PICU at any given time are those that most need oxygen, for there are functioning O2 ports built into the wall of this room, a rarity in other locations. Beyond this limited support, in addition to standard IV fluids and possibly medications from the hospital’s strained pharmacy, the child must maintain her or his own vital signs. In many cases, the children do. In the cases where they do not, another death follows, in most cases a preventable one.

If you continue down the hallway of Ward 8, you will pass a small workroom on the left, where nurses and doctors congregate when not at the bedside. The room is plain, with only various bulletins adorning the walls, many from past HIV/TB public health campaigns.



If you find yourself peering in this room, you may notice that uniformed nurses within eye you suspiciously. Don’t mistake it for hostility. This is the look they give the “short-termers”. Rare is the visitor to Ward 8 that stays longer than a few days or weeks. Most new faces, I would guess, stay but a few minutes, seconds even.


Don’t get me wrong. Short-termers care immensely for the children in Ward 8, and they want to help, to make things better, to change things. They are usually deeply moved by what they see on the ward. I suspect you will be too.

I know about short-termers because I have spoken to them as they wander through Ward 8. I know about them because I myself am one.

The nurses are not short-termers. They went to nursing school because they too want to make things better in Swaziland, and they want to do it for a living. Most of them are Swazis, and were trained at the local university. The Swazi nurse uniform they receive at the end of this training is more like a military garment than the cheery, flowery scrubs that U.S. nurses wear. The Swazi nurses wear their uniforms proudly.

They can be found in Ward 8 every day, in uniform. They see a child die on many of those days. There is little cheer in this, and usually little they can do about it. There are around a dozen nurses that rotate through Ward 8, but only two or three on at a time. The average patient census is around forty, the children are often very sick, and supplies are few.

Between checking on the 25 sick children under their care, they might look at you suspiciously, but don’t take it personally. It is just that they have heard the short-termers’ words of encouragement, the promises, and still, a year or more later, they are working in an ill-equipped, crowded ward, except this year the ward is slightly more crowded because more children are presenting with acquired immunodeficiency syndrome.

You see, HIV treatment for kids, available for many years in rich countries, is just now becoming consistently available in Swaziland. As the Baylor clinic and its partners scale up such treatment, the inpatient pediatric census will likely drop substantially, but for now up to 80% of the children are HIV-positive.

Though I would like to promise the Ward 8 nurses that we will decrease the number of children in the hospital, I refrain. They would only eye me suspiciously, and rightly so. I have been in the hospital a total of four days, in Swaziland for three months. I am a short-termer.




Continuing down the hallway, we come to Cubicle #1, the first large room on the right. Before entering, you can see through the glass panels that there are approximately 12 cribs lining the walls, except for the far back corner which has a long platform with dividers, where infants can be laid side-by-side. Up to three patients can be assigned to each crib, but usually there are only one or two. Beds are shuffled around as needed for older patients.

The room itself is not unpleasant. It is recently painted, with at least some perceivable ventilation through the back windows. The temperature in the room, as a result, is actually agreeably temperate. The primary smell is faint and is that of kerosene, which is sometimes used as an antiseptic for the floors.

Each child is coupled by a caregiver (usually the mother, aunt, or grandmother), who provides for the child’s basic needs. The hospital provides the food (though the formula supply is sometimes interrupted), and the caregiver feeds the child. The nurses’ role is to administer medications, troubleshoot and coordinate patient care with the doctors.

Cubicle #1 is reserved for kids with infectious disease diagnoses. Most of the patients have a respiratory ailment (pneumonia, tuberculosis, asthma, etc.), but diarrhea, meningitis, and others are not uncommon.

Neighboring Cubicle #1 is Cubicle #2. It is reserved for surgical patients. Children recovering from accidental trauma—complicated burns, fractures, etc.—are monitored here. (Such trauma is not uncommon in Swaziland, given open-flame cooking, lax traffic laws, and the density of pedestrians along major roadways.) Children with other surgical needs (intestinal obstruction, ostomy revision, appendicitis, mitral valve insufficiency, etc.) are also assigned to Cubicle #2.

As you arrive at Cubicle #3, you will notice a small mural on the left. The painting depicts many of the characters from Disney’s The Lion King. It is nice to look at, and seems to be the project of a former short-termer, as it is beginning to show signs of wear.

Cubicle #3, the last door on your right, is for chronic patients, namely those that need intensive nutrition or long-term antibiotic therapy. They are segregated from Cubicle #1 to control infection as much as possible, but patients with TB (diagnosed and undiagnosed) can end up in any room.

Swaziland has the highest rate of TB in the world.

The cubicle system is certainly not perfect, but lest you find yourself surprised by this, I will point out that Ward 8 does not always have running water, much less soap. N-95 masks, HEPA filters, negative-pressure rooms, individual patient isolation are science fiction here at MGH, regardless of your TB status.

On that note, if you want to diagnose military TB or TB of the spine, you have to do so without cross-sectional diagnostic imaging. Pictured below is the local government hospital's cat scan machine. It broke some time ago and there are neither the parts or the expertise to fix it. The elevator met a similar fate, so the cat scanner was placed where pictured to keep patients from entering in the stagnant elevator car.




This brings us to the last door on the tour. Through the door there is a small room, about five square meters. Some call the room the “laundry room”, for indeed it is where the sheets and other linens are washed. I have heard others call it the “room for abandoned children.” Indeed, the room is also full of children without a home.

The children are between 1 month and ~10 years of age, and most appear relatively healthy (though a good proportion are suspected to be HIV positive). They all have different stories. Some are orphans. Some are developmentally delayed. Some just moved over from Cubicle #3, having nowhere else to go, and nobody to go to. Regardless of the events leading up to their confinement to the back of Ward 8, they were now under the care of a few dedicated women who feed, change, and clothe them between loads of laundry.



This concludes your tour.

--

Any walk through of Ward 8 forces the walker to ask difficult questions. I am not an expert in asking difficult questions, and am the most amateur of amateurs in offering meaningful answers to these questions. Such answers, I might add, are well beyond the scope of this blog, and well outside of my zone of personal comfort.

With that said, I will quickly address one question that often nags me when I am faced with unnecessary childhood suffering and death. The question is this: When a child suffers or dies a preventable death from a treatable disease, is it because that child is less valuable to those in charge of protecting him or her from harm?

My answer: No.

As I see it, there is a difference between the capacity to love and care for another human being and the capacity to intervene. I have seen too many desperate, mournful mothers and fathers to believe that indifference blunts the pain when a child hurts or dies.

Love and care are fundamental to humankind, and they cost nothing. Intervention, on the other hand, is not free. The capacity to love and feel is inborn, but the capacity to place a child who cannot breathe on a ventilator is not. It is expensive.

Rare is the society that can support high-dollar intensive care medicine for children.

Very rare is the society that does not wish to defend the health of children and does not wish for a state-of-the-art children’s ward and PICU.

Extrememly rare is the opportunity to have wishes come true when you live in a country where the vast majority are feeding, clothing, and sheltering their family on little more than a dollar a day.

--

Yesterday, a Swazi told me a story about a group of four children he came across near his small village in the hot, dry eastern lowveldt of Swaziland. The oldest was approximately 10 years of age, and she was accompanied by three younger siblings. The 10 year-old was wearing underwear, and the others were completely nude.

The four naked children, he explained, had been walking for 30km looking for their grandmother. Their mother had died the day prior, and the oldest child had led them on a search for their nearest known relative.

The 10 year-old was confident that they were almost there.

--

My answer to the above question is “no” because I am certain that the mother of these 4 children did everything she could while alive to ensure that her children would not have to walk nude and aimlessly across arid countryside in search of someone to feed, shelter, and clothe them. She did all she could, but it was not enough.

Poverty and sickness did not make her care less. Poverty and sickness took away her ability to protect her children from becoming orphans with no place to go.

To understand Ward 8 and the values assigned to the lives within, it is necessary to first understand this country’s poverty and the sweeping effect of HIV/AIDS among its people.

This understanding is not acquired over the short term.

The Baylor International Pediatric Aids Initiative just became the largest effort of its kind in the world. To read more, check out the following Houston Chronicle link.

http://www.chron.com/disp/story.mpl/front/4338729.html

A brief encounter with a weaver bird

The weaver bird. What a fascinating animal. Yesterday, while reading an article in the Economist magazine (which I recently discovered has some distribution in these parts), I noticed that one of these birds had landed on my patio chair. The chair is one of those nylon camping chairs, and is dark (or Duke) blue. The bird was similar to the one pictured, quite pretty to look at.

Weaver birds seem to spend essentially every waking moment tirelessly building and remodeling their nest. This one, it seemed, was foraging for building supplies.

I marveled at how many bones he must have in his neck, or rather how accommodating those bones must be, for his head could achieve impossible angles as he looked around.

Now to the fascinating part. After scanning the totality of my back porch and lawn, the bird darted directly toward the sliding glass door with such swiftness that I thought he would disembowel himself on it (for I have seen this happen). At the last instant, he threw back his ultra-limber neck and did a midair about-face. All I heard was a tiny click on the glass, and suddenly the bird was back on the chair.

Faintly in his beak, I saw what looked like a 2cm thread, a small, thin blade of grass. With that tiny piece of vegetation, he darted off. Curious, I stepped toward the glass door. To my surprise, I had been observing the bird through a delicate spider web, and in the web were a few tiny bugs and some debris, with a small interruption in the web where the bird had extracted his small discovery.

That small filament, as I type, is no doubt woven into the wall of one of the nests I see high in the pine trees outside of the dining room window from which I type.

What am I up to? (5 Nov – 12)

In the interest of sharing a few more of the day-to-day details of my life here in Swaziland (as requested by a few of you), I offer to you this update:

The past week began and ended with travel. I returned from Malawi on Monday afternoon and saw patients in the clinic--i.e. the Baylor Center of Excellence (COE)--Tuesday through Thursday.

My three clinic days were typical clinic days. I arrived at the COE at 7:30 or so, waved as I walked in through the waiting room, and headed to the kitchen to prepare a cup of instant coffee. This ordinary entrance is followed by a “quick” check of the emails I received while sleeping, not-so-"quick" connection speed permitting.

[As foolish as it might sound, I still have conceptual difficulties with the undeniable fact that my today is somebody else’s yesterday, and that when I arrive to work on Tuesday, Monday is simultaneously out there somewhere. In any case, I tend to receive email messages in the middle of the night, and check them when the senders are just entering REM.]

The instant coffee helps me clear this up inside my head, and, once situated in time, I grab the first patient chart, usually around 8:00. Some time between 9:30 and 11:00 I happen to pick up the chart of an English- or Portuguese-speaking patient and the SiSwati translator goes to tea. A mid-morning break is a foreign concept to many, but I can assure you that if it is one’s job to accurately and tactfully translate the things that come out of my mouth, she deserves tea.

Patients continue to come and go throughout the morning. Some are very sick, and some are not. All, with rare exception, are HIV positive. (Those that are HIV negative are able to see a physician on the day they are screened, but are then referred to the local general pediatrics clinic, as it is our mandate to care for HIV-infected children and their families.)

On a typical day, lunch comes at around 1pm and ends shortly thereafter, when I pick up the next chart.

An average day’s patient volume will be around 12-16 patients per physician (similar to subspecialty clinics in the US).

Patients usually come in groups of 2, but some are seen individually, and families of three or four not uncommon. Two-thirds to three-fourths of the patients I see are children, and the rest are adults. There is always an available internist or family practitioner if I find myself inundated by complaints of lower back pain, hypertension, etc, and need to consult an old-person-doc.

Approximately half of the patients seen are on antiretroviral medications. The other half are being monitored and treated until their CD4 counts drop to the range where ARVs are indicated. Most patients come in for scheduled visits (routine labs, adherence checks, clinical follow-up, nutrition/social worker counseling, med refills, etc), but a handful drop in because they are ill and need to be seen without an appointment.

On a typical week, I admit one (maybe two) children to the hospital. This process is well-known to any outpatient physician, but here in Mbabane there is one significant difference—the hospital often has fewer resources than the COE. To minimize the effect of this disparity, we do as much as possible for the child before the child is transferred, and we communicate directly with the doctors receiving the patient at Mbabane Government Hospital. To ensure adequate follow-up and to help address some of the hospital’s unmet needs, we also assign at least one Baylor Aids Corps physician to round during the week at “MGH”. (I will be there next week, so stay tuned for more on this.)

Patient care usually wraps up between 3:30 and 4pm, at which time we typically have informal meetings, review labs, or continue working on other projects (PMTCT, improving clinical protocols, nutrition program development, training preparation, etc.)

This, in summary, is a typical clinic day. I hope this description answers more questions than it generates. If not, let me know and I will elaborate further.

Friday was filled, as usual, with administrative and academic meetings. We discussed TB protocols, a recent patient death and its most likely causes, the Malawi COE network meeting, and more.

As I stated, last week ended with travel. A mere 4 hours southeast of Mbabane, there is a beautiful bay (called Sodwana) that is also a South African national park. They say that the diving there is second only to the Great Barrier Reef. This has to do with the diversity of fish and coral, the visibility, and other underwater details. For such details, ask one of those people with that rectangular red and white scuba sticker on their back windshield. They will know.

I went to simply spend a day on the beach, and I did just that. We left for the beach Saturday at 6am, and came back early Sunday.

Sunday evening, I read some of Sachs's “The End of Poverty” before closing my eyes, jealous that everybody in Texas was just sitting down to Sunday brunch (a tradition I would trade for morning tea any day), and hopeful that the book on my nightstand was correct and that the world was indeed on track to change for the better.

My Swazi family

Meet my youthful housemates.

Well, actually, Busi (the tall, grown-up one) lives in the adjoining guest house, while Phephisa, Thando, Neliswa, Philile (left to right in bottom row) and Ntshiki (in Busi’s arms) come and go between Busi’s home village of Siteki a few hours east.

The two little ones are deathly afraid of me (as pictured), and I have no idea why.

Phephisa and Ntshiki are Busi’s children (she has a third child of fifteen years). Thando and Neliswa belong to Busi’s sister, Sphephile, and, finally, Philile is the child of Busi’s other sister, Futhi.

Such names make “Ryan” seem a bit of a yawn, no?

HIV in the Swazi media - Part 1

Swaziland National Emergency Response Committee on HIV and AIDS (NERCHA);
AIDS awareness campaign billboard


Recent headline in one of Swaziland's leading newspapers. 

Standing on shoulders – A brief tribute

Liquid antiretrovirals, formulated for children too young to swallow pills.


I am not a laboratory scientist. I did not painstakingly develop AZT, 3TC, d4T, nevaripine, and the other antiretrovirals that keep HIV-positive children alive.

I am not a clinical researcher. I did not keenly design costly, intricate clinical trials to ensure the safety and efficacy of these drugs.

I am not a visionary. I did not partner with a multimillion dollar pharmaceutical company to ensure that these drugs would be available at or below cost in Africa, where they could save tens of thousands of young lives.

I am but a pediatrician and amateur blogger. I examine sick kids, give them medicines, and when able share a bit about my experiences.

This past week alone, thanks to the people above, our clinic here in Swaziland was able to offer hundreds of children life-saving HIV treatment at no cost. Around Africa, other clinics like ours are doing the same.

Without these individuals, these children would die.

For this reason, this pediatrician/amateur blogger would like to say, “Thank you. For what it is worth, thank you very much.” 

Where to plant a yellow rose

A yellow rose outside our clinic. Mbabane, Swaziland


Late one afternoon last month, I stood outside the Baylor COE clinic and watched two landscapers discussing where to plant some recently-delivered flower bushes. Though I did not understand what they were saying, both seemed to be making a careful argument regarding aesthetics, light, shade, etc. They eventually agreed on a bare spot in a nearby bed and began picking up the flowers.

As they passed, I noticed they were yellow roses.

They were not quite like the oft-cited yellow roses that grow in east Texas, the kind that cost 60 bucks a dozen (an average Swazi’s monthly salary).

The stems were pragmatic and wiry, the thorns few. The petals were smaller and less compact, almost indelicate.

The flower was not slender and romantic like the ones we used to distribute to unsuspecting coeds on Texas Independence Day back at UT-Austin.

I remember those afternoons fondly, riding the campus shuttle around the university’s 40 acres, giving away roses, asking nothing in return.

An all-too-rare gesture.

As the gardeners carried the pots across the lawn, the yellow roses of Swaziland bounced with each step. They nodded at the mid-afternoon sun, as if reminding me that home was still out there.

Reminding me that I too was changing. 

Lake Malawi’s #1 Boy Band

“Look, the moon is full,” said one of the silhouettes as we wandered down the shore of Lake Malawi.

“I believe it is actually a waxing gibbous,” one of my other traveling companions objected.

Regardless, we did not need a flashlight as we sought out the pizzeria down the beach from our thatch-roofed cabin.

Nor did “Lake Malawi’s #1 Boy Band”.

They use the name “Boy Band” for short.

One instant, we were discussing the moon, pizza toppings, and how hungry we were. The next instant we were being entertained by a four-piece-two-dancer band, average age 6.5 years.

Boy Band someday hopes to buy trousers to go with their matching shirts.

These children are an affirmation of hope, a reminder of what we must strive to protect.

Have a look…


Boy Band's bass guitarrist.


Boy Band's backup drummer.


Boy Band's lead guitarrist.


Boy Band's dancers, demonstrating the ever-popular "old man dance".

To be continued... 

Lake Malawi's #1 Boy Band, continued.

Boy Band's lead percussionist, lead singer, and leader.


The Boy Band drum set. (Note the bottle caps.)


What I hope is Boy Band's smallest audience for years to come, for they deserve no less than fame and furtune.


Behold the future of Malawi...

Looking for a good cause for holiday giving?

Swaziland has the world's highest rate of HIV infection, and the disease is creating a generation of orphans. The country has nearly 70,000 orphans, and over 15,000 Swazi households are headed by children who are raising little brothers and sisters by themselves.

Please check out the following link as you make plans for holiday giving.

http://www.youngheroes.org.sz

What am I up to? (30 October – 5 November)

Some of you have asked me to post intermittent "informational" blogs about my day-to-day, and so I begin with this past week, which I spent outside of the kingdom of Swaziland in the country known as "the warm heart of Africa"--Malawi.

Malawi, as you will see below, is a beautiful country, and this past week happened to be the site of the biannual Baylor International Pediatric Aids Initiative (BIPAI) network meeting. The conference and associated gatherings took place Monday-Thursday, and included representatives from all of the BIPAI-affiliated sites (Botswana, Burkina Faso, Lesotho, Malawi, Swaziland, Uganda, Romania, and others). I was lucky enough to participate.

This is a photo of Dr. Kline during the opening session. He is reminding us why we are here.



Note that Africa is fiery-red. If you have access to an alarm bell, please ring it.

The network meeting, in short, is a time to share ideas, innovations, and clinical cases to ensure a coordinated, proactive and united front between the many centers.

The meeting corresponded to the opening of the Baylor Center of Excellence in Malawi, the construction and operation of which is being largely funded by the Abbot Fund and UNICEF. It is a beautiful, functional building (see photo below), and it will be the home base from which the Baylor Aids Corps physicians in Malawi will care for HIV positive children and families, broaden similar services to health centers nationwide, and coordinate HIV training and prevention strategies.


Banda, Republic of Malawi Minister of Foreign Affairs, left, and Reeta Roy, Abbott Laboratories Divisional Vice President for Global Citizenship and Policy, unveil a plaque commemorating the event.

If you want more details on the meeting or the opening, check out http://bayloraids.org/programs/malawi/ or simply email yours truly. 

Malawi photos

Lilongwe's "Black Stars" soccer team (managed by David Jones, a BIPAI colleague) take on presidential guards' team on field near presidential palace. Final score: Stars 1, guards 6.



Roadside shop selling toys and baskets.



Malawi is Africa's most densely populated country. Houses (such as these) dot the landscape.



Malawi baobab at dusk. 

Lake Malawi photos (4 November)

Canoe carpenter, Cape Maclear, Lake Malawi


Children, Lake Malawi.


Children with fresh catch, Lake Malawi


Children fishing, Lake Malawi