Wednesday, January 31, 2007

Two more reasons I like Maputo - capoeira and the seawall mural

Capoeira by the bay.

Capoeira is an Brazilian martial art developed by enslaved Africans starting in the 1500s. It originated in Nigeria nad Angola, where fighting between rivals was done to music. Participants form a 'roda' (circle) and take turns playing instruments, singing, and sparring in pairs in the centre of the circle.

Today, the game [usually] involves no actual contact and is marked by fluid, acrobatic play as well as feints, subterfuge, and extensive use yoga-like poses in quick succession. Among advanced players, sweeps, kicks, and headbutts are delivered and evaded with incredible precision.

Technique, strategy and fitness are essential in capoeira, as is the berimbau, a single-stringed percussion instrument. The berimbau is basically a musical bow (4 to 5 feet long) with a steel wire stretched across it and a gourd tied to one end for amplification.
Three berimbaus.
Note the two berimbau players behind the dancers. There is a tambourine and a tom-tom as well.

Capoeira by the bay, 4 seconds later.
If you turn 180 degrees, with your back to the capoeira and the bay, you would see this mosaic. If you were to take ten steps forward, you would see that the mosaic consists of many many 2-4 cm ceramic fragments.

Sea wall mosaic.

Sea wall mosaic, 4 meters over.
Though I asked the artists (pictured below) about the mural , I could learn little about who commissioned it or how long it was destined to be. They were just happy to be doing a shady section.

It was approximately 200 meters as of three weeks ago, and growing.
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Listless lists - How I decided to go home for the holidays

Entrance to "Phelps Ranch". Note the 'P' above the longhorn.

One day in late December last year, the Baylor clinic where I worked switched to a skeletal staff and patients stopped coming. I was on call early on that first skeletal week when our usually bustling clinic became just another one of the many quiet, empty buildings that stand in Mbabane waiting for 2007, waiting for ‘business’ to resume.

The weeks of late December and early January are weeks when Swaziland slows to a crawl and the national focus is on the church and the family. Parents who are away from home working travel back to their villages, and children who are away from home do the same.

On that day in late December, our clinic was empty except for me. The waiting room was vacant, quiet.

I didn’t like it much.


Familiar sounds, I find, can be quite calming. To me, the din of a pediatric waiting room is calming. It reminds me that there is work to be done, for the work itself is making most of the noise.

I was assigned to the quiet, empty clinic all day on that Tuesday in late December, in case a patient arrived with an emergency and needed of a doctor.

It was still early and there were no emergencies. I was listless, restless, with nowhere to go.

I needed my ipod.

I had left the ipod at home.

No noisy patients and no Beatles.


On a typical clinic day, I arrive between 7:30 and 7:45. As I walk up to the main entrance of the clinic, I can already tell if it is going to be a busy day by the number of parents sitting on the waiting room benches. The children are usually running around or fastened tightly to the back of a seated mother, and are therefore much more difficult to count.

Patients begin arriving up to two hours before I arrive, and if more than forty beat me to the clinic, my colleagues and I can expect to see patients until at least five o-clock. If there are fewer, we can take a break for lunch, perhaps even check email or read an article while the translator has a brief tea break mid-morning.

In any case, it is my practice to peer through the glass as I arrive.
Then comes my favorite part of the day, or at least one of them—the instant when I open the door and enter the room where the patients are.

I try to remember to open the door slowly, for rare is the morning when there is not a child playing just on the other side of the tinted glass. Once inside, I speak some sort of greeting (sometimes in English, sometimes in SiSwati), though I do not speak so loudly that it obligates a reply, so as not to interrupt ongoing registration, triage, small talk, or play.

Our waiting room has a high ceiling and walls of concrete. Every noise made is heard at least twice as it bounces about, and sounds dissipate slowly, as there is little fabric to absorb the sounds except the clothes of those waiting there. A child’s laughter, therefore, can fill the room, but usually the room is dominated by the reverberation of several simultaneous speaking voices and at least one two-year-old’s Oscar-worthy temper tantrum. Other age groups sometimes join the dramatic protest, usually shortly after or in the anticipation of having blood drawn. In the late afternoon, a few children cry because they are hungry.

Sometimes, when I arrive a bit later (~7:45), the loudest noise in the waiting room is the voice of one of our nurses, who gives daily waiting room talks about the importance of knowing one’s HIV status, minimizing stigma, and related topics.

After smiling and saying “good morning,” “sawubona”, “hello” or “unjani”, I check the doctor’s chart box to see how many patients have been triaged. I then slip into exam room 6, 7, or 8 in the back hallway. I close the door, for the noise from the waiting room easily reaches the back hallway. I open the exam room window (better ventilation = prevention of TB and other airborne pathogens). After organizing my reference books and signing on to the electronic medical records system, I open the door and follow the echoes until I am back in the waiting room.

Then, for one instant, as I [gently] shout out the number of the next patient in line, my voice is heard above all others. A brief lull in the rumble of conversation follows. As soon as someone rises from their seat and begins gathering his or her child(ren) and belongings, the rumble resumes.


In late December, the clinic was all lull and no rumble, and I sat in silence.

Our clinic wiating room after closing time.

Man, how I lamented leaving my ipod at home. How I wished that the internet was fast enough to listen to KFOG online.

San Francisco radio at its finest.

I started reviewing labs and entering them into the database. Four hours passed, albeit tediously.

I needed a break. I walked the empty halls of the clinic. I ate two chicken hot dogs.

I returned to my desk. Still no noise. Still no emergencies.

I thought about running home to get my headphones so I could listen to Rocky Raccoon.

But, what if I was not around for the one big emergency of the day?

I tried again to log onto KFOG. No luck. Not even close.

I had heard that one way to calm (or at least distract) a restless, listless mind was to make lists. I had counted sheep once before, and it helped. This was sort of like making a list.

Having no better idea to pass the time, I took out the notebook where I sometimes jot down ideas for things to write about.

My first list was a list of potential emergencies that our patients might have to face while the clinic was closed (for the following week the skeletal staff became no staff and the doors to the clinic were to be locked).

List #1: Potential patient holiday emergencies
- Lost ARVs
- Spilled ARVs
- Ran out of ARVs for some other reason
- Forgot how to take/give ARVs
- Got very sick
- Got very very sick
- Had no food for child

List #2: What the patients could do in case of holiday emergency
- Come see the on-call physician (at least for the first week of closure, when we were on duty)
- Call our on-call pharmacist (available through holidays to cover all ARV issues)
- Go to Mbabane Government Hospital (MGH), which was going to have some staff in place for inpatient and outpatient care (for the very and very very sick, albeit with the limitations of a poorly funded public hospital). For more on MGH, see my two previous blog posts, “You have the wrong hospital” and “A matter of conscience.”

My second list stopped there, for I could come up with no holiday solution for food insecurity. I hadpersonally never known a holiday without excess food; the notion of hunger on the holidays saddened me.

List #3: Why the Baylor clinic was closed in the first place
- Baylor clinic staff had not had a day off since the clinic opened in February 2006.
- They needed time off.
- It is customary in Swaziland for outpatient clinics to close for the days around Christmas and New Year.

List #4: What are my plans while we are closed?
- Drive up Mozambican coast and camp
- Mountain bike in the Drakensburg Mountains
- Maybe a brief safari along South Africa’s coast
- Catch up on reading, that is to say continue to sift though the large body of literature on pediatric HIV so that I might someday be able to call myself an expert.

This was the holiday I had planned, and I had been looking forward to it. It was going to be cheap, relaxing, adventurous, and all of those other adjectives that people seek when planning an exotic road trip. It was going to be the perfect hiatus, the ideal respite to get some summer sun and ward off burnout.

I was to leave the day after tomorrow.

List #5: Why am I so restless
- It is very quiet
- There are no patients to see
- This list-making is not working
- For 30 years straight, I have always been home for the holidays, and this year I would not be

List #6: Why I am not going home for the holidays
- Far away
- Expensive
- I have no plane ticket

List #7: Why I would [perhaps] rather go to Texas than Mozambique, Lesotho, and South Africa.
- My brother (birthday = late December)
- My sister (wedding anniversary = late December)
- My brother-in-law (“ “)
- My mother (wedding anniversary = late December)
- My father (“ “)
- My aunts
- My uncles
- My cousins
- My cousins, once-removed (I think that is what they are called)
- Grandmommy
- Granddaddy
- Chad (my friend since kindergarten)
- I can go to Mozambique, South Africa, and Lesotho next year, perhaps on the weekends
- I live year-round in Swaziland, an exotic place in its own right
- Besides, Texas is arguably exotic as well, in several ways

List #7 was much longer than #6, I realized.

One email and two hours later, I had my flight. Eighteen hours after that, I was on a plane, homeward bound for the holidays.

Monday, January 29, 2007

Photos added to recent posts

I fixed the images for the last few posts. Sorry for the delay. Have a look. -Ryan

Recent Media - Sick leave for an unhealthy health minister

Might South Africa move beyond [Dr.] beetroot?

For those following the antics and missteps of the South African Ministry of Health's clumsy reponse to HIV, please have a look at the recent op-ed from the Chicago Tribune. Thank you, Delouis, for forward this to me.

A coup that could turn the tide on AIDS Chicago Tribune


Window shopping - Mercado Artesanato, Praca 25 de Junho, Maputo

I came across these photos yesterday. They were taken two weeks ago, during a most pleasant weekend in Maputo with Nanda, Andrew, Amy, and Izze. It you see anything you want, feel free to place an order. I export for friends, with an agreeable commission of zero percent.

Oil cloth paintings.

Wooden bowls and vases.


Shells and coins.

Window shopping - Mercado Artesanato, Praca 25 de Junho, Maputo, continued


Statues with many heads.

Woven baskets.


Sunday, January 28, 2007

Tangled net

As you have noticed, I have had difficulty recently with posted photos not appearing on the site. Unfortunately, the internet is too slow to fix them this weekend, or for that matter to post new entries. Hopefully matters will improve soon. When they do, I will add updates. A pleasant Sunday to you. -Ryan

Wednesday, January 24, 2007

Gardening in Swaziland

I live in Swaziland, and Swaziland is far away from home. Even as the 747 flies it is an impressive distance. Heck, the 747 even has to stop for gas on the way. As you know, the 747 holds a lot of gas. It does not, however, hold enough to get from where I am from to where I am now without stopping to get more.

Much of my time way over here, therefore, is spent making home seem closer than it actually is. This is why I have a Texas flag flying in my front lawn and this is why I have photographs of my family just inside my front door. I see those photos at least twice a day, going and coming.

It is nice.

To make home seem closer, I also host frequent barbeques. To further shorten the distance, I am having a friend of mine share with me his carefully-guarded tortilla recipe and rolling technique. (Tortillas here are imported from NYC, and that is too much time on a 747 for a tortilla. They end up both broken and a dollar each.) I already have collected a few margarita recipes, but Mbabane has been out of tequila for a few weeks, or perhaps I just don't know where to look.

In any case, there is nothing quite like a fresh burrito and margarita to make Texas and California seem just outside my front door, as they so recently were.

As a man cannot ward off homesickness with flags, photos, grilling, burritos and margaritas alone, I recently intensified my bring-home-to-Swaziland strategy for warding off excess nostalgia.

I took up gardening.

As a Texan, I suppose that I should pretend that I grew up farming, and that I only garden because I am no longer back on the farm.

Well, I did not grow up farming. We did keep cows and horses, but in my eyes they were for fun, sort of like big, fenced-in pets.

We did have a garden, though, and an impressive one, if I remember correctly. We grew zucchini the size of bowling pins. We used to supply our entire zip code with homemade salsa from our tomato/onion crop. We grew brussel-sprouts, strawberries, onions, potatoes, okra, pumpkins, an assortment of peppers, asparagus, carrots, yellow squash and plenty more.

Well, I am ashamed to say that my garden is not so impressive. There is nothing the size of bowling pins, and the tomato plants are falling over because I have not tied them up properly. I have little diversity, and if I were a subsitance farmer I would not be able to subsist.

Still, the garden looks pretty, and I really enjoy my time sowing and reaping on my tiny plot (pictured above), even if there is little to reap. Just this morning, in honor of the recent Swazi harvest festival (see entry below subtitled "Ryan's brush with royalty"), I picked my first butternut squash. To the best of my knowledge, it is the first butternut squash ever grown in a Phelps Africa.

It is a very small butternut squash, but I took the photo from an angle that makes it look more like a bowling pin, because I do have my pride to protect.

Next is a photo of my fledgling corn. The row on the right is maize, and the left side is sweet corn.

Though I do not have a picture of it, I also have a young lime tree. I am still in the market for an agave plant. While I have no plans to buy, feed and slaughter chickens or livestock, I do have many of the key ingredients for margaritas, salsa, and vegetarian corn-tortilla burritos just outside my front door. (If you like meat in your Swazi Tex-Mex, don’t be discouraged. We can either catch one of the neighbor’s obnoxious guinea fowl simply buy some beef at the store.)

So, if you are ever far from home, homesick, and somehow near Swaziland, drop by and we'll scavenge the garden for something edible and familiar to take the edge off that homesickness.

Tuesday, January 23, 2007

Recent UNICEF press release and one person's reaction to it

Thank you, Annette, for forwarding me this jolting email from Tim France in response to UNICEF's recent press release ( Reading it was similar to dunking my head into a bucket of ice water.

Hold your nose, y'all.

Tim France's email:

"Whatever you do UNICEF, accentuate the positive. I am getting so tired of the habitual practice of big agencies pumping up the positive side of anything they do on AIDS, and leaving the bad news for the small print. It is so dishonest and deceitful.

I have just read the latest and most staggering example I can recall, in a UNICEF statement from a couple of days ago.

Instead of launching your one-year stock-take of the 'Unite for Children, Unite against AIDS' campaign, why don't you just admit it UNICEF, progress on the global response to children and AIDS is appalling, and no amount of media spin will change the numbers.

One year after the launch of the campaign, a press release with the headline: "Signs of progress and momentum in global response to children and AIDS" does nothing to mask the fact that prgress against the campaign's four 'Ps' are nothing short of shameful. Trying to claim otherwise to placate your donors, or whoever it is you are stroking, is reprehensible in my opinion.

1. Preventing mother-to-child transmission of HIV:

Despite your focus on the handful of "countries that have achieved breakthroughs in preventing HIV transmission from mothers to children," the overall access of pregnant women with HIV to ARVs is still only 9%.

You were right to refer to that as "unconscionably low."

The Campaign goal for this 'P' is: By 2010, offer appropriate services to 80 per cent of women in need

2. Providing paediatric treatment:

How the global average of "one in ten children needing antiretroviral treatment receiving it" constitutes progress is beyond me. And indirectly claiming some of the credit for the paediatric formulation price reductions negotiated by the Clinton Foundation - which surely is something UNICEF itself should have been blazing a trail on long ago - is manipulative and conniving.
The Campaign goal for this 'P' is: By 2010, provide either antiretroviral treatment or cotrimoxazole, or both, to 80 per cent of children in need

3. Preventing infection among adolescents and young people:

Again, you choose to accentuate the positive by saying: "The stocktaking report notes that prevention responses are displaying renewed attention on the need to focus strategies on adolescents and young people most at risk."

I am not even sure what that means, it is such circuitous wriggling. The 2006 AIDS Epidemic Update, published just two months ago, describes the state of this 'P' very clearly:
"In many regions of the world, new HIV infections are heavily concentrated among young people (15-24 years of age). Among adults 15 years and older, young people accounted for 40% of new HIV infections in 2006.

The Campaign goal for this 'P' is: By 2010, reduce the percentage of young people living with HIV by 25 per cent globally

4. Protecting and supporting children affected by HIV/AIDS:

The UNICEF statement really clutches at straws for something self-congratulatory to say here, by referring to the significant reduction "in several countries" between orphans and non-orphans in access to education.

In one of his last addresses as UN Special Envoy for HIV/AIDS in Africa, Stephen Lewis said in 2006 that our response to the needs of children affected by the epidemic was "microscopic". He also said:

"It is impossible to understand how, in the year 2006, we still continue to fail to implement policies to address the torrent, the deluge of orphan children."

One of the chilling pieces of data UNICEF should be emphasizing is that only three to five per cent of orphans receive any intervention of any kind from the state.

The Campaign goal for this 'P' is: By 2010, reach 80 per cent of children most in need
Just what is it that UNICEF is afraid of? Why can't they just tell the truth?

Thank goodness that some journalists have taken the trouble to read the report for themselves, and conveyed the considerable disappointment that UNICEF should actually be communicating about it:

"Few pregnant African women get AIDS drugs: UNICEF" (Scientific American)
"African moms still pass on HIV to kids" (Pretoria News)
"UN Report: Response To Children With AIDS Insufficient" (All Headline News)
"Spread of AIDS to children slowing, but picture bleak" (Canadian Broadcasting Company)
"UN Says Global AIDS Effort for Children Falls Far Short" (New York Times)"


Sunday, January 21, 2007

Japanese brunch in Swaziland - An exercise in culinary syncretism

My inside-out Swazi sushi roll (in the making).

My Mozambican shrimp nigiri (made).

The first course.

The first course, w/ Andrew and Nanda. Below, the second course w/ Ryan.

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The Swazi Ncwala Harvest Festival - Ryan's brush with royalty

The king of Swaziland.

The Ncwala, meaning “First Fruit”, is the Swazi harvest festival. The event honors the King and the Kingdom’s ancestors. It is held in December or January every year. The exact date is chosen by Swazi astronomers and depends on the position of the sun and the phase of the moon.
The Ncwala festival has two parts: the Little Ncwala and the Big Ncwala. The Little Ncwala begins when the Swaziland-based Bemanti clan, or the 'water people', travel to the Mozambican coast and collect the foam from the ocean waves, which they transport back to their native villages.

The Big Ncwala begins when, under the full moon, the youth of the villages begin to collect the sacred branches of the Lusekwana plant (a species of acacia) which they use to build a sacred garden. Tradition states that the plant will wither and disintegrate in the hands of a youth who has lost his virginity, and so the branches, once collected, are well cared for.

The festival also includes the slaughter of a bull, traditional song and dance, and the dressing of the King in ceremonial dress. On the last day of Ncwala, the King, who has been in seclusion for several weeks prior, enters the sacred garden of the Lusekwana branches and consumes the first fruits of the new season (usually the year’s first harvested pumpkin). Once the King has eaten, he shares the pumpkin with his warriors and emerges from the enclosure to bless the Swazi people and their ancestors.

After this blessing, the Swazi people themselves are allowed to consume the remaining first fruits of the annual harvest. The festival ends with the ceremonial burning of [some] of the King's belongings, an act which symbolizes cleansing and preparation for the upcoming year.

The Ncwala festival’s duration depends on the behavior of the sun and moon, but generally lasts up to three weeks. This year, the festival ran a bit late and, though I missed the Mozambican foam-gathering, I was able to catch the ceremony’s finale in early January (the day when the King eats and emerges from seclusion and bless the Swazi people). In an additional stroke of good luck, I was mistaken for a member of the international press and, as His Highness was about to emerge from the garden (just after pumpkin-eating inside), I was carefully ushered through the metal detectors for a close-up view of the king and his warrior entourage.

Below you will find selected photographs and observations gathered in the minutes after this fortuitous case of mistaken identity.


My fated journey through security.

The traditional Ncwala uniform of the Swazi warrior was feathery and furry. The warrior’s feet were usually bare. Each ankle was encircled by a loop of white, brown, or black cowhide, as these are the colors of Swaziland’s trichrome cattle herds. Earth-toned cotton fabric was wrapped around the waist. The material had the texture of a crisp, new bedsheet, and was patterned with simple circles, boxes, or lines in some variation of bovine colors, though occasionally a warrior appeared wrapped in fabric with subtle hints of other natural colors, those beyond the cow spectrum (beetroot, squash or carrot, etc.).

Over the waist-wrap, many warriors wore a pelt of leopard or cowhide.

A fellow photographer (warrior-photographer, that is).

Above the waist, there was more inter-warrior variation. Many of the men were shirtless with strips of cowhide around their neck, similar to the ankle loops but with longer hair. Many wore necklaces and bracelets made of small vividly-colored plastic beads, the only obvious interruption in the otherwise organically-themed uniform.

Swazi warrior.

From the fighters’ mid-biceps hung long (30-60cm) tufts of cow hair, apparently from the tail of the animal. It was very coarse in appearance and feel, and gave the illusion that shoulders and arms were broader than they would be without the hairy appendage.

A similar but longer bundle of hair (60-90cm?) surrounded the neck of approximately half of the fighters, giving the appearance of a lion’s mane and effectively disguising any underlying musculoskeletal frailty.

Warriors with manes.

Those warriors with the status and royal lineage that permitted them to don a headdress did so, and it was constructed from tall, black feathers, with red and sometimes yellow feathers intermingled. The result was a sudden increase in the wearer’s stature, a nice accompaniment to the brawny, hairy accents below.

In one hand, the warriors carried a leather shield the shape of an American-style football (but larger and flat), which was stitched to a two-meter wooden rod much like a football’s grip is woven into the underlying pigskin. In the other hand, they carried another long straight, darkly-colored stick (origin and significance unknown).

Such was the proud, elegant uniform of the harvest-time Swazi warrior. Made locally, well-ventilated, and adapted over centuries to inflate and camouflage the Swazi tribe's protectors while belittling and intimidating those who would might seek to do the tribe any harm.

As the king was about to exit his sacred garden (a fort-like enclosure of several dozen square meters with walls of long sticks buried side-by-side in the dirt), a loose ensemble of approximately one hundred Swazi warriors spontaneously gathered at the entrance of the compound.

The amorphous battalion.

They emerged in a cluster and began dancing and chanting. While most faced forward and some stood shoulder to shoulder, many casually ambled about. There was talking and laughing. The King of Swaziland emerged and positioned himself at the front of the slow swarm.

His mane was the broadest, his cow hair the puffiest, his feathers the tallest. His feet were sandaled.

As the amorphous warriors advanced from the fort, he led them in their relaxed, festive advance until, approximately 50 meters in front of the gate, they encountered a regimen of distinctly different soldiers. The soldiers had been waiting there for some time.

These soldiers wore imported polyester suits with shiny black shoes. Their creased pants and sports-car-red jackets were accented by white faux-leather belts and bleached gloves. They clasped a semi-automatic rifle in their lily-white right hand. Their woolen navy-blue hats fit snug and low, shading the eyes. The strong sunlight reflected off the tips of their noses and pursed lips as they stood motionless in formation, their intentionally solemn faces forming a long wavy line, for the ground beneath their feet was slightly uneven.

The polyester-clad soldiers.

The king's procession.

The king approached the soldiers and walked ceremoniously and slowly among the ranks before rejoining his warriors and returning to the fort, at which time Swaziland was officially granted permission to eat freely.

Monday, January 15, 2007

A matter of conscience - Rounding with Dr. Akingbe

Dr. Akingbe can come across as stern. His black leather shoes are often covered with plastic booties, for in a pediatric ward many things are spilled, spat, dribbled, and so on, and these substances end up either on shoes or, if you wear them, plastic booties.

Dr. Akingbe always wears his white coat, which is no longer entirely white, for not all spills fall uninterrupted to the floor. His pockets contain tongue blades, a few blank green discharge forms, and a black coiled stethoscope. On the left breast of his off-white coat, there is a small beaded ornament affixed with a tarnished safety pin. The beads are tied together in rows with thread so that they create a mosaic of a red AIDS ribbon. The thread is also soiled, worn. The beads and thread curl up at the bottom.

Dr Akingbe has a mustache and expressive, worried eyes. When you look into them, you feel as if you are being asked a question, and not just any question, but a very difficult one.

Dr. Akingbe speaks with a determined voice, and speaks loudly, louder than he needs to in order to be heard. His mild Nigerian accent adds additional emphasis to his words.

His accent has echoed through Ward 8 for nearly ten years. Ward 8 is Mbabane Government Hospital’s (MGH) pediatric ward, where Dr. Akingbe cares for some of Swaziland’s sickest children. (See previous entry-"You have the wrong hospital"-for more on Ward 8).

Ward 8 is permeated by the sweet, mentholated scent of kerosene (used for scrubbing the floors) and the sweet, smoky smell of a still, warm room where dozens live and sleep. The strong smells compete with each other, and both dissolve into a thin film that coats the back of your throat if you spend more than four consecutive hours there.

Ward 8 has limited nurses, limited medicines, limited equipment, limited everything, with two exceptions—sweet, pungent odors and sick-sick-sick kids. Dr. Akingbe knows the ward's smells, diseases, and limitations as well as anybody, and he has not yet tired of talking about them.

“We are using the mother’s as nurses, but they are not!” he recently professed as we waded among the children during bedside rounds. He went on to say, “It is possible to say that a thing should be done.”

Dr. Akingbe says things like this, and when he does, everyone in the room hears him, for he speaks such words forcefully, perhaps in the hopes of being not only heard but also understood. In this case, he was advocating for the hospital kitchen to provide enough food to feed the mothers who are boarding with hospitalized children and providing round-the-clock nursing care. (At MGH, even food is limited, and current policy allocates meals to breastfeeding mothers only.)

In a loosely-organized monologue spanning the remainder of the morning consultations, Dr. Akingbe went on to say,

“If someone is incapacitated and we are here to help and we don’t help, we are saying we don’t care.”

After pausing to examine a patient and jot down a treatment plan, he continued, “It is not going to add anything to my salary; it is a matter of conscience.”

He reached into the crib of an emaciated child. After laying hands on the young, diminished body, he picked up the order sheet and asked if the child has received the required volume of high-calorie formula. Receiving unknowing glances from each of us, his eyes again became question marks, and for several seconds he peered around the room to ensure that everybody understood the obvious question. One nurse broke the silence, and in a quiet voice, said, “We will do it.”

“There is a difference between saying ‘we will do it’ and yourself doing it.”

Dr. Akimbe can come across as stern.

As if to lessen the blow, he suddenly began to describe nutrition programs in other hospitals where he has worked, describing how enjoyable it is to see children get stronger, fatter. He spoke of well-organized, well-funded malnutrition programs in Uganda and Nigeria. He spoke of effective protocols, dedicated staff, death-defying results.

“Why can’t we do the same?”

As if answering his own question, he muttered, “They didn’t get the enthusiasm in one day.” His voice was now softer, his eyes more distant.

In pediatric training, young doctors learn all about the effects of chronic severe malnutrition on a young body. Arms and legs the shape of underlying bones, inelastic skin, swollen tissues, mucous membranes fading from crimson to pink and eventually blush-white, as blood cells themselves starve to death.

We also learn about how long-term calorie deprivation can create more subtle findings, such as diminishing a child’s level of alertness. Even the strength and quality of a young voice can fade. A scream becomes a squeak, then a whisper, then, eventually, quiet ensues. Such is the famished body's last-ditch strategy to economize.

I never appreciated this fully until I began rounding at MGH. In Ward 8, wispy voices and distant eyes abound.

There are too too many hungry, frugal bodies in that place. Too many voiceless, subdued children.

After completing rounds, my colleague Nanda and I offered to help Dr Akimbe with the day’s procedures (blood draws, IV placements, etc.). He sent us to place a nasogastric tube in a three year-old. The child’s arms and legs were like bamboo. At the bedside there was a container of brown formula, similar in color to a coffee with two creams, but cooler and much more nutritious. The hospital kitchen mixes this formula, called F75, every morning.

The volume of F75 that this severely malnourished child needed to take to gain weight was large. They might as well have delivered a lumberjack breakfast, or perhaps fitted the child with a snorkel. It was a mismatch, so much so that I initially thought that the wrong container had been delivered to the bedside.

This dilapidated 3 year-old would never be able to drink enough F75 to grow. Hence, our being sent to place a feeding tube.

He coughed as the NG tube passed through his right nostril and down his esophagus. In his left nostril, another tube hissed softly with moisturized oxygen, for his lungs were also sick. How sick it is hard to say, for there is no pulse oximeter to measure blood oxygen levels in the MGH pediatric ward, and chest x-rays require the mother-turned-nurse to take the child across the hospital campus, a difficult task when portable oxygen is unavailable.

HIV in Africa is a thing without mercy.

As I tore off strips of paper tape and secured the feeding tube to the patient’s face, the child’s mother asked me how much F75 she should push through the syringe every hour. I told her, and asked the patient’s nurse to ensure that the mother understood the basic technique.

“I will do it," she told me.

After bidding a temporary farewell to Dr. Akingbe, I walked with Nanda toward the parking lot.

I looked forward to lunch, for I had not eaten breakfast, and the mild taste of petroleum and honeyed body odor lingered around my tonsils.

Friday, January 12, 2007

I blame the net.

Going to Mozambique this weekend, where the internet is faster. Will post from there...

Thursday, January 04, 2007

Et tu?

Happy 2007.
Parson the recent lull in my entires...

The new year has been distracting. I blame Caesar for that.

You see, Caesar is credited with moving the New Year from the Vernal Equinox to January 1 and the Babylonians are credited with the first New Year's resolutions. New Year’s resolutions go back about 4000 years, when the ancient Babylonians resolved to return any farming equipment they borrowed during the year to their rightful owners in time for the start of the new year, then the vernal equinox (~ March 23).

Well, the ancient Babylonians might be surprised to learn that returning farm equipment did not make the US government's official website ( discussing the most popular US resolutions.

They are as follows:
Lose Weight
Pay Off Debt
Save Money
Get a Better Job
Get Fit
Eat Right
Get a Better Education
Drink Less Alcohol
Quit Smoking Now
Reduce Stress Overall
Reduce Stress at Work
Take a Trip
Volunteer to Help Others

I will reserve comment on these, except to say that, in my opinion, it is a good thing that half of them relate directly to health, and that volunteerism is a deserving resolution #13.

The Babylonians would have liked #13, as it relates to giving something back.

As for my resolutions, I am still trying to come up with some I can keep.

Here is one: I will continue blogging and get better at it.

Thus resolved, I will write more soon...