Needle, thread, and the year ahead -- A brief preamble to the overdue do's of '07

The art of embroidery and quilt-making in Southern Africa has a history of reflecting social change. Artists portray current issues through their art, in this case expressing how people and communities cope with HIV/AIDS. Messages of awareness, choice, prevention, and solidarity appear on these tapestries. Such messages are timely this time of year, I think.

As 2007 draws near, I have been thinking about what I should resolve to do and not do. The three do's stitched above will almost certainly make my list.

Thanks for stopping by the blog. More on the new year soon...

www.library.northwestern.edu/.../tapestries.html

Thinking outside the condom box - A news story

According to this week's issue of The Economist (the one with a sinister-appearing Putin on the cover), the "incredibe melting condom" is out there, and maybe heading to a neighborhood pharmacy near you....after it has been proven safe for human use, of course.

Before you picture (as I did) a condom-shaped apparatus that melts like one of those Listerine breath strips, have a look a the article link below. The melting condom actually changes from liquid at room temperature to solid at body temperature.

A Listerine breath strip in reverse.

Gasp.


In my experience, the solid-at-body-temperature phenomenon was a characteristic unique to cheese fondue when eaten in excess.


Of course, I am no polymer chemist. Chemical bonds and the study of such bonds have not interested me since I mistook that vial of super glue for eye drops back before I knew better.

Now I know better. Do I ever know better.

In any case, the melting/solidifying condom is an interesting (and apparently potentially practical) idea, and I thought that this was a good article to post with the slightly less, er, "innovation-oriented" article discussed in the entry from earlier today.

After all, if HIV were not a complicated problem, it wouldn't be such a large problem.

There is no problem, no matter how complicated, that does not contain hidden within it potential solutions.

Take the Trojan Horse, for example.

A better example, perhaps, is this: female disempowerment and the unpopularity of latex sheaths (both realities in much of Africa) imply the need for a female-controlled, non-latex alternative.

So, click below, and behold the "incredible melting condom!"

http://www.economist.com/science/displayStory.cfm?story_id=8407243

Culturing HIV - A news story

If you have access to the Wall Street Journal from yesterday, either online or in ink, please check out the article titled "African Monarchy Sparks a Debate Over AIDS and Sex" by Michael M. Phillips. (Thank you Joel and Dan for pointing this article out to me.)

The story summarizes many of the challenges that are inherent in this work. As understanding necessarily precedes the advent of effective solutions to these challenges, I invite you to have a look and share your ideas.

For those without access to the WSJ, the article points out recent comments made by a popular talk show host with royal connections who is willing to do a lot of showy talking about HIV, such as declaring condoms "un-Swazi" and ensuring his listeners that he never dons the device. He recently stated that groups addressing HIV and AIDS in Swaziland are "full of half-truths and lies."

Hmmm.

The article goes on to discuss Swaziland's monarchical traditions and offers an impressive (if not slightly pessimistic) survey of Swazi culture as it interfaces with the epidemic. The article sets the stage, but sets it somewhat drearily.

I do not mind dreary, necessarily. If the weather is dreary, you dress accordingly. If [sometimes] detrimental, entrenched cultural practices and loose-mouthed talk show hosts are in the forecast, they too can be addressed. I assure you that they are much easier to shape and dress down (respectively) than meteorological phenomena.

In its final paragraphs of the article itself, there is a break in the clouds and the author offers some hope of a solution. He suggests that Swazi culture, with all of its uniqueness and nuance, actually has potential to become a tool for combatting rather than perpetuating the epidemic.

I agree. Do you?

An offer of solace and hope

If you want to offer some solace and hope, please consider giving to Young Heroes.

You will change the life of an AIDS orphan. (www.youngheroes.org.sz)

Have a look at the following video clips, both 30 seconds long. (Link: www.stephenlewisfoundation.org/publicserviceannouncements.htm)

Nothing to be proud of - global ARV coverage

My assessment: not enough orange.

Antiretroviral Therapy Coverage Rate in Low- and Middle-Income Countries Global Data, June 2006; Country Data, December 2005 *

* See http://www.globalhealthfacts.org/topic.jsp?i=11#map for an interactive version of this map, with specific data points. The "coverage rate" is a measure of the number of people receiving antiretroviral therapy divided by the total number of people estimated to need treatment. Data were not included for countries that are not considered to be low or middle income or for countries where data were not available.

Holiday office bbq (or "brie" in the local parlance)

Note the "Don't mess with Texas" apron.

I built the grill myself. (Really.)

My back yard.

The new skinny on circumcision - A news story

Egyptian circumcision (Pritchard 1954)

For those of you that keep up with these types of things, check out the latest news on circumcision as a strategy to prevent new HIV infections (as summarized by the NY Times article linked below).

For those who prefer a summary “snippet” (couldn’t resist), two big trials (in Kenya and Uganda) were stopped early this week after data showed that new HIV infection among circumcised participants was much less than non-circumcised. The reduction was near 50% in both trials, and was even higher in a previous French government-sponsored trial, which showed a 60% reduction.

The reduction is believed due to the presence of particular sentinel immune cells on the underside of the foreskin (Langerhans cells) that like to attach to the virus, leading to infection.

Policy implications are not entirely clear as of yet (and the costs/benefits as compared to other interventions are still being worked out), but everybody can certainly expect skyrocketing demand for the procedure to get rid of those pesky immune cells and the foreskin where they live, at least among many HIV negative African males.

While I personally prefer HIV education to scalpels, it seems circumcision has suddenly become cutting edge.

Have a look: http://www.nytimes.com/2006/12/14/health/14hiv.html?hp&ex=1166158800&en=299e031e4a678f86&ei=5094&partner=homepage

Gone - A patient encounter

(Swazi sunset over cane fields, as seen from from Melandelas)

I learned something yesterday. I learned what it feels like to be the last doctor to see child before that child dies.

I hadn’t even picked up my first chart when I saw the family walk in early yesterday morning. Well, it had been a family. Mother, father, baby.

Yesterday morning, no baby.

The father looked up at me and said, “My baby is gone. He’s gone.”

I looked at him puzzled, as if to say “where to?” Indeed, that is what I wanted to know.

The baby had been in mom’s arms in my exam room a mere seven days before. I watched the baby feed vigorously. I treated the baby’s thrush. I complimented the "family" on their hard work, for the child had been born over two months premature, and they had kept him going, against plenty of odds, for his first month of life.


I had been so proud that the child, who desperately needed ARVs, had made it to our clinic, and together we made a plan that I believed would keep the baby alive.

The father saw that I did not understand where the baby had actually gone.

He leaned toward me, and with the soft squeaky voice of one severely burdened spoke one solitary word,

“Funeral.”

There are instants when there is no pride in my work, only humiliation.

I was humiliated. As I relive the instant, I still am.

I fixed my eyes on his, and said, “I am so so sorry.”

The truth was that I knew nothing of sorrow. This man, a week before, had told me he would do anything for his child, his now-dead child. His wife, the mother of the child, has AIDS, and could die any day, even with careful treatment.

I can be as so so sorry as I want to but I know nothing of such pain.

The father must have noticed the void look in my eyes, for he put his hand on my shoulder and said to me,


“It is all ok. It is all with God. God knows.”

I believe that this is what he said, verbatim, with his right hand on my left shoulder.

I paused, then responded as well as I knew how: a hand on his hand, a bowed head, and sorrowful, regretful, hopefully caring expression.

My gestures were appropriate, I suppose, but is was abundantly clear that this man with a dead baby and his hand on my shoulder was actually the one comforting me, and it pained me even more to think how wonderful this man would be as a father—strong, centered, faithful, even affectionate in the most desperate of circumstances.

Yes, if I didn’t know better, I would say that he was destined to be an outstanding father.

I said goodbye to the bereaved parents, walked down the hall, up the stairs, and to the chart room. I took the deceased patient’s chart from the shelf, looked over it, and sought out two other pediatricians to briefly discuss the case with me.

Hindsight combined with the scrutiny of my trusted colleagues suggested that I probably could not have saved the baby.

As I wrote the letters "R.I.P." on the manila folder encasing the patient’s brief medical history, I promised myself this:

Next time (and God knows there will be plenty of next times), I am damn well going to try.

Happy holidays from Swaziland, with love

Joy to the world – A holiday wish list

I keep this blog for a few reasons. I enjoy putting my thoughts into words, for one. I also like to keep family and friends up-to-date, and phone calls across the ocean can cut deeply into the small salary of a Swaziland-based pediatrician. Lastly, and perhaps most importantly, I want to generate interest in this type of work. I want people to better understand HIV in Africa, and I want them to sincerely believe, as I do, that there is much we can do to alter the epidemic's destructive course.

I have been thinking a lot about this blog of late. You see, the internet here is Swaziland is abysmal, and postings can take hours, if the connection is available at all. Moreover, I sometimes do not know what to write about, or, better said, what people want to read about.

Also, I am a terrible typist. At times, I have wondered if the time hunting and pecking on my laptop keyboard is time well-spent.

--

When in Africa during the holiday season, I have noticed that time seems to drag a little. Maybe it is because the days are longer, maybe because there is less “holiday activity”.

Some time soon, my father will hang up enough lights to put Clark Griswold to shame, and I will not be there to operate the staple gun. My mother will hang the tree ornaments that I made in kindergarten, back when HIV was killing Africans but not Westerners and therefore did yet not have a name. I will not be there to help Mom untangle the hooks, to reminisce.

Over the next three weeks, I will not be there to film an amateur holiday video with my cousins. I will not participate in the "white elephant" gift exchange or the informal touch football game. I will not sing holiday songs as my brother strums the guitar, sitar, ukulele, mandolin, steel guitar, banjo or whatever other stringed instrument he has recently mastered. I will not be able to sit with my sister and brother-in-law and ask them how medical school is going. I will not make cookies, venison sausage, pecan pies, pumpkin pies, eggnog or cider. I will not participate in the holiday poker tournament, talent show or pizza contest. I will not dress up as Santa Claus and ask the under-fives what they want from the North Pole.

I will not get to hug anybody that occupies my family tree and say “Merry Christmas”. Not one.

You see, over the next three weeks, I will for the first time in my life experience the holiday season without seeing any of my lifelong family.

This is an inescapable part of my job, to be far away from home.

I have accepted that.

--

For most readers of this blog, faraway-ness and HIV are going to be forever coupled, for thousands of miles separate you from this imperiled population.

This brings me back to my third and final reason for maintaining this website in the first place: I want to tell candid, interesting stories about what I am seeing, to share my joys and frustrations. I want to offer reading that helps the tragedy of this disease to seem closer, more real, so that you will better understand why I am afraid for the future southern Africa, why I am giving up the living-room fireside of my childhood home on Christmas morning.

There is no place more sacred, more meaningful, to me than that place early on December 25th. I can assure you of that.

I want this blog to help readers realize how much you can do from afar, even from your very living-rooms. I want you to believe that distance does not disqualify anybody from being part of what I see as the most pressing challenge of our new century—to mitigate and turn back this most un-merry epidemic.

I keep this blog because I believe that, if we are to deck the halls (and we should deck 'em), we need to also work hard to ensure that “faraway” people do not die by the millions from a treatable disease. If we are to celebrate (and we should celebrate), let us also celebrate our collective refusal to allow a preventable, treatable virus to conquer a subcontinent.

After all, what does the nativity scene mean in a world where thousands of newborns are contracting a disease when we know very well that maternal to child transmission can be prevented?

As someone who still believes in the promise of a benevolent Santa Claus, let me ask this: Who is this modern-day, pudgy Nordic fella who delivers thousands of virtual reality video games to wealthy kids while thousands of Africans die? Can his elves not be taught to make AZT instead of X-boxes?

I am not saying that nice presents are not nice to give and nice to receive. They are nice.

And, I am not saying that Nintendo is bad, that such games do not help children develop hand-eye coordination. They certainly do.

It’s the heart-mind coordination that I worry about. What gift, I wonder, nurtures that essential axis?

I don’t know the answer to this question, but I expect that is hard to find at your local electronics store.

So, though I am distant from most of you, please allow me the following holiday wish list. It contains but three wishes:

(1) The holiday season is considered a time for charity. Most nonprofit organizations receive >50% of their donations during this time. If the oft-cited spirit of the season catches you, please visit the website for “Young Heroes” (www.youngheroes.org.sz). It is a no-nonsense local NGO that puts resources directly into the hands of Swazi families supporting one or more of Swaziland’s 70,000 orphans. Your entire donation will be utilized on the household level, and will be closely monitored. Please do give if you are so inclined. Click on the website or the logo below for more information.

(2) Please send me comments or emails to guide me as I write about my experiences here. If you have ideas as to how to make this blog more poignant, I would really like to hear them. Have a look at what I have been writing so far, and please be blunt and up-front. I am new to blogging and highly adaptable.

(3) May the year 2007 bring you and yours joy and health, that you may resolve to share it with others, to spread it near and far.

From Swaziland, with love and hope, Ryan

The sky is falling – A tale of natural disaster

At first I thought someone had thrown rocks through my windows. Then I thought better. Swaziland, after all, is not a violent place. Nor does the rock hypothesis explain the rest of the damage.

As I looked around my house, I saw fallen trees, grounded power lines, holes in neighboring roofs, and, scattered throughout the lawn, branches and white plastic. The white plastic was a bit of a mystery until I realized that the plastic gutters lining my roof were swiss cheese, and each plastic piece corresponded to an identically shaped hole overhead.

While I still have no notion of how they make the holes in swiss cheese, I quickly realized that my Swazi homestead (and its gutters) had been the victim of a sizeable hailstorm.

The air was cold. Really cold. Not Africa-in-summer-time-unseasonably-cool, but cold.

A group of my colleagues and I had been in Mozambique for the weekend and arrived home at dusk last night, an hour or so after the storm, when we first noticed the carnage.

I was glad that we had stopped for a half hour for gelato on the way out of Maputo, and that we had been detained for a similar time period by a stern, ill-tempered Mozambican highway patrol cop. That had saved us from driving through during the frozen barrage.

As soon as we switched our phone cards to the Swaziland network, we began hearing the stories. A man hit in the face by falling ice, now at the hospital for reparative surgery. Ice penetrating tiles and wood around Mbabane and landing in peoples living rooms. Ice destroying cars, crushing windshields. Hail the size of small cantelopes.

I am no meteorologist, and I am no physicist. If I were, perhaps I would understand how a chunk of ice smaller than a small cantelope remains airborne long enough to reach a small cantelope’s size. As a non-weatherman, I assume that a bit of airborne ice must be like a snowball rolling downhill, gathering mass and momentum as it descends, until eventually it crashes missile-like to earth.

One does not come to Africa expected to be bombarded with large chunks of ice from the sky. I expected swelter and sweat, not melon-sized hail, especially in December, one of the subcontinent’s hottest months.

--

According to those watching the storm, the hail lasted a minute or so.

I wondered if anyone had died. (I will check the newspaper.)

I wondered if, for that one minute, the hail storm caused as much damage to Swaziland as HIV did.

If HIV fell from the icy sky and broke things, would we pay it more attention?

What am I up to? (26 November - 10 December)

The clinic has been increasingly busy, and I have started to get the hang of outpatient HIV care. Our electronic medical record system and clinic flow keep getting better and better, and hopefully will stay a step ahead of our growing patient volume.

I do not yet have the recent numbers from our data people, but I can say that recently I have been seeing many more new patients coming for first-time screening. We do very little advertising, and so word of mouth seems to be a very effective PR tool in this small kingdom.

We are facing some challenges on that front, however. Because of the quality of our facilities and services, it is clear that many patients are coming to us from long distances despite the availability of nearby HIV clinics. This is a reflection to our dedication to excellent patient HIV care, but reinforces the need for continued outreach. Efforts to this end are vigorous, but early progress is always gradual. (The somewhat dense meeting minutes I posted a while ago list some of our early-stage outreach activities.)

I am still spending most of my time at the main clinic (the “COE”), which has allowed me to gain much needed experience in the approach to the HIV positive child (as well as adult). The clinical experience is incredibly diverse, from scabies to myiasis, eczema to zoster, asthma to TB (pulmonary and extrapulmonary), foreign bodies in the ear to esophageal candidiasis.

I see basically a little bit of everything—tropical, general, infectious, chronic, bizarre, hum-drum. My patients and their illnesses run the gamut.

In my nonclinical work time, I am helping to develop pocket-sized abridged references for the COE health care workers, especially for those students and residents that will soon be passing through, as the learning curve here is by necessity quite steep for those unfamiliar with HIV care. (It certainly was for me.) These condensed reference cards will also be potentially useful for Swazi health care workers at other sites, and can be distributed at future trainings.

Leisure in Swaziland remains easy, as leisure should. I do plenty of running and biking, and conditions in this temperate, mountainous region are ideal for both. This past weekend traveled to Maputo (3 hours away), where the sunshine, seafood, and Brazilian music are plentiful.

In other news, I recently bought a cheap, second-hand station wagon, fuel-efficient but also good for hauling things (many Texan’s pre-requisite for any auto purchase). I drove it off the lot with no warranty (which is why it was so imminently affordable), and realized shortly thereafter that the wipers did not work (a novice auto purchaser’s oversight). When the rain inevitably started to fall two minutes later, I was forced to drive the 20 kilometers home with my head hanging out the window.

Lesson learned = when buying used cars, seeing the road ahead is more important than a few extra cubic feet behind.

In any case, if you find yourself carless/truckless on a rainless day in Swaziland and you have somethin’ for haulin’, and you can limit the “soccer mom” jokes, call me and I will bring the station wagon over. Wait a week, and I can come by rain or shine, as I will have replaced to wiper motor.

World AIDS Day photo montage

December 1, 2006 was the 18th annual World AIDS Day. That's me, Ryan.

Wolrd AIDS Day was the day when several dozen grandmothers (gogos) dressed in traditional Swazi attire and waved wooden spoons and leather shields.

It was the day when several hundred Swazis marched through the street carrying signs and chanting such words as "Keep the promise." That promise is for a future when a third of Swazi's are not slowly (or not-so-slowly) dying of a treatable, preventable disease.

It was the day when NERCHA and the Swazi MOH kicked off a new educational campaign, with slogans such as these:

December 1, 2006 is no different than the other 364 days of 2006. Every day is a struggle to protect the vulnerable from this epidemic, to protect ourselves. Following 2006, there 364 more days waiting, plus the inevitable 19th annual day the world will call attention to this humanitarian disaster, and to our successes and failures as aspiring humanitarians.

Though it is a day of hope, I cannot help by ask myself how much people really care. When the parade and speeches are over, do we still care enough to succeed?

I guess that is up to us, isn't it?

No photos for now

Alas, I am unable to post photos at this time. I will resume posting as soon as possible. -Ryan

So December 1st was World Aids Day. So what?

Here are a few million "what's" to mull over.

New HIV infections in 2006 = 4.3 million (UNAIDS/WHO 2006 report)
AIDS deaths in 2006 = 2.9 million (UNAIDS)
Deaths in sub-Saharan Africa in 2006 = 2.1 million (UNAIDS)
Total deaths = 25 million since 1981 (UNAIDS 2006)
Total infections = 65 million since 1981 (UNAIDS 2006)
Total children orphaned as of World AIDS Day 2006 = 15 million
Country with highest infection rate = 33.4 percent in Swaziland (UNAIDS 2006)
Proportion of new infections in sub-Saharan Africa that are women = 2/3(UNAIDS 2006)
Proportion of those needing ARV treatment who receive it = 24 percent (UNAIDS 2006)

P.S. Most HIV+ people don't know they're infected.

Photos coming...

Internet is too slow to post photos. Will post tomorrow, technology permitting. -Ryan

Today is World AIDS Day, 2006

Swazi child. (www.ifrc.org)

Stay tuned for photos from Swaziland on this important day. Will post soon.

Please visit www.worldaidsday.org for more information.

Please visit www.youngheroes.org.sz to donate directly to support families with orphaned children here in Swaziland. This organization spends its money very carefully.

If a Bono fan, check out http://www.joinred.com/news.asp for a video blog from the man himself.

Thank you for visiting...