My TB skin test result

Induration created by the TB skin test. (www.stanford.edu/class)

My result = negative at 72 hours. (Zero induration.)

So...no INH needed for now.

But I definitely need to be better about wearing a mask around long-term coughers to avoid the next one looking like the above photo…

Why I love my job – Quote 1 of 10

Mother administering ARVs to child. (www.beatit.co.za/images)

The following is an excerpt from a dinner conversation with Ms T Mamba and A Makhanya of Cabrini Ministries here in Swaziland.

“People were dying like flies. There were funerals up and down.

Then the medicines came…the medicines were like a miracle.

Now people are living.”

Why you shouldn't go indoors - Two toilet stories

Latrine and boy. (news.bbc.co.uk)

This past week, I attended a meeting of child survival “stakeholders” hosted by UNICEF and the Swazi Ministry of Health and Social Welfare. I will fill you in on the details of this meeting before too long.

In the interim, I wanted to share two interesting tales related to water closets. These were extemporaneously delivered by two of my Swazi colleagues at the end of the second day of the two-day meeting.

Story time was not part of the meeting agenda, but rather stemmed from a series of technical difficulties. Intermittent power-outages had confused the PowerPoint projector, and the conference had temporarily ground to a halt.

Sharing stories, as you all know, is a nice way to spend time. (I hope this is the case, for it the primary premise of this blog.)

As far as stories go, I am always impressed by how animatedly folks embrace the topic of toilets in particular. It certainly was a common theme growing up in the Phelps household in Denison, Texas.

Even better is when potty stories are juxtaposed with a very important but admittedly dry health policy debate. In this setting, the animation doubles and the audience is all the more riveted.

My written version of the narratives below will be abridged and at times paraphrased, and I assure you it will be no substitute for the real thing.

[Before I continue, by way of justifying the following content, let me point out that there are nineteen officially designated “high impact child survival interventions” that comprise the modern-day, global strategic framework for keeping children under five years old alive. One of the nineteen is “use of improved sanitation”. Another is “use of improved drinking water.” Hold that thought, as I will revisit it at the end of this entry.]

--

Toilet story #1 (told by a high-level Ministry of Health and Social Welfare official):

“People, I have a problem. It is with my mother-in-law.”

She stood and walked to the center of the room.

“She won’t use the toilet.”

Confused glances circulated the room.

“I mean, she won’t use the toilet in my house.”

“Why?” a UNICEF rep asked.

“Yeah, why?” the World Vision attendee echoed.

“Because it is inside the house,” she said, as if that was somehow a clarification.

She went on to say, “Can you help me?”

“How about a pit in the garden?” said a voice in the corner, perhaps that of the Lutheran Development Services member.

“She says it is too close to the house,” answered the MOHSW official.

“How about a pit latrine?” was the suggestion of Save the Children’s liaison.

“How does that differ from a pit?”

“Privacy?” Red Cross answered.

“Maybe,” one of the orphanage coordinators said, “you can go farther away from the house.”

“Too many neighbors.”

A nun with another orphanage said, “Can’t you just dig a hole wherever she wants?”

“She is not comfortable with a hole in the garden…”

Ten seconds of silence.

We had run out of ideas.

“My mother-in-law is so strange.”

“No,” objected the representative of the Boy Scouts of Swaziland. “This is common.”

“Oh, I thought it was just my mother-in-law.”

“No, this is quite common,” he repeated. Many in the room were nodding.

“Wait wait!”

We all wait-waited, hoping that the gentleman speaking, who reprensented the Traditional Healers Organization, had a solution for us.

Instead, he said, while jumping to his feet, “I have a story!”

--


Story #2 (no intended pun)

He told the tale in SiSwati, with great to-do, and translated it afterwards. The translated version was something like this:

“Let me share another problem about toilets…Mmm.

[In Swaziland, “Mmm” is a common, how shall I say, rhetorical insertion, used to signify an inferred consensus when a suggestion is made and nobody objects. It is as if to say, ‘As there is no dissent, I will continue now.’]

He continued, “Last week, one of children had an accident, the type one has before training to use the toilet.”

[By the way, in much of southern Africa, the words ‘washroom’, ‘bathroom’, ‘restroom’, ‘loo’, ‘little boy’s room’, etc. are rarely used. The best word for the room (and the seat) is ‘toilet’.]

“The other children thought the accident was amusing, and so I took the opportunity to shout at them.”

“I said, ‘I do not want somebody in my family who indiscriminately disposes of human excrement in my house!’”. He shouted as if he were really shouting at his kids, firmly but kindly.

With a look of half light-heartedness, half dismay, the storyteller continued.

“Then, one of my son’s said in response: ‘Dad, so this means that we are that kind of people that you talk about, because we use the toilet in the house.’”

The room erupted into laughter and applause.

End of story #2.

--

While I initially did not understand story #1 (i.e. how one could possibly have an aversion to using an indoor toilet or prefer an outdoor option), story #2 (and the audience’s response) helped me better understand why one might have this preference.

--

Ten percent of the Swazi children who do not live to have a fifth birthday die of diarrhea. Safe drinking water and adequate sanitation, the pillars of diarrhea prevention, depend on the time-tested adage “don’t poop where you eat.”

AIDS-related infections kill 47% of under-fives in Swaziland, and good water and sanitation practices prevent many of these infections.

Where and how one decides to evacuate does not only make for entertaining stories; it also prevents or invites disease.

So, while I am not going to boycott the comforts and familiarity of indoor WCs, I will say that the mother-in-law and child do make a good point.

My TB skin test

My TB skin test site (inside the red circle).

The last line of the previous entry refers to the many new “victims” of TB, and perhaps the overall tone of the excerpt was a touch cynical.

Sorry 'bout that.

It’s just that there is a lot of TB here in Swaziland.

A good portion of our clinic patients are infected.

--

On a different but related note, I recently had an “indeterminate” TB skin test (TST). I mentioned it at the end of an entry a couple months ago, I believe.

“Indeterminate” essentially means not obviously positive but not exactly negative. In other words, the half-dozen docs I asked about the swelling at the site of the TST injection could not agree as to whether the area was swollen enough to be unequivocally positive.

In short, the vote was essentially split as to whether or not I have the bug in my lungs.

If I do, it is almost certainly in the earlier and less serious ‘latent’ phase and not the ‘active’ phase, which is accompanied by coughing, fevers, and all of the symptoms you associate with tuberculosis.

The "conversion" from nonexposed to exposed in not uncommon, and happens frequently among health care workers who work with TB-infected patients.

--

In any case, because I am naturally interested to know if I am hosting some uninvited mycobacteria, I repeated my TB skin test today (see photo above), and I will let you know what it determines.

If I do have TB in my lungs, I will simply take medicine for 6ish months until it is no longer there.

In addition to reading yesterday’s entry on World TB Day 2007, you can read more about TB in my February excerpt describing an encounter with a TB patient (“An old woman is looking for you”).

Blowing out candles – World TB Day 2007

Recent headline in Swazi daily paper.

Days that are named after diseases come and go, usually unnoticed.

No department store sales. No gifts or candy. No bunny, elf, or fairy comes to visit.

No songs. No feast. No costumes. No egg nog.

No cake. No candles.

Yesterday was World TB day: TB’s closest thing to a birthday party.

Don’t know how old the mycobacterium is, but it’s very old.

Swaziland, where I live, leads the world in TB prevalence.

TB is second leading cause of death from infectious diseases worldwide, second only to HIV/AIDS.

Compared to TB, HIV is a baby. (Ambitious, yes, but young.)

Swaziland leads the world in HIV prevalence.

According to the World Health Organization, TB kills nearly 2 million people worldwide every year.

2 plus six zeros.

2,000,000

The number looks bigger if written like this: $2,000,000

A big number.

New TB infections occur at a rate of approximately one per second.

That equals thirty to forty new TB cases since you read the title above.

Numbers such as these are humiliating, apathy-generating.

Numbers with so many zeroes tempt well-meaning individuals to say,

“Too [darn] big.”
“To [heck] with it.”
“Not my [ ] problem.”

(The brackets often contain a spectrum of colorful vocabulary that I try to avoid on this website.)

Humiliation and rhetoric aside, TB is indeed our problem.

Alas.

Alongside HIV, it is very much my problem. 78% of TB patients here have HIV. Many of my patients have both.

Like HIV, TB is smart.

Like HIV, it is capitalizing on weak treatment programs worldwide and learning how to outwit our inconsistent medicines.

Unlike HIV, it knows how to fly.

--

The Swazi Minister of Health, WHO Country Representative, and National TB Program Coordinator recently met and reviewed some of Swaziland’s tuberculosis numbers:

· TB accounts for approximately 25% of admissions in Swaziland hospitals
· 20% of institutional deaths in Swaziland are due to TB
· TB has increased 600% in the past 15 years in Swaziland

Only an estimated half of Swaziland’s TB cases are being treated successfully.

Fifty percent is nothing to be proud of, for TB can be treated with a simple and inexpensive treatment program.

Themba Dlamini, the ministry’s TB Programmes Manager, summed this up in a recent interview.

“TB is curable,” he said.

When TB treatment programs are sloppy, however, the bug becomes resistant to these simple and inexpensive cures.

This is all very old news, but, as you can see in the illustration above, every so often it still makes the front page of the Swazi Observer.

Dr. Paul Farmer, the co-founder of Partners In Health , has dedicated much of his career trying to get this old news out, to renew our sense of urgency.

His [paraphrased] mantra if this: “MDR and XDR-TB highlight a global failure to prevent and treat basic TB.”

Until we stop failing, this old, airborne germ is not going anywhere, except of course to one new vulnerable person per second, one new victim in one of the world’s poor places.

The frightened, frowning child - A patient encounter

A frowning Swazi child (not the one in the story below, mind you).

“She is scared.” Pretty said.

I had never met a Pretty before. Fear, on the other hand, is routine around here.

Pretty is a gogo. For you newer readers, “gogo” is the word for grandmothers around here.

Pretty was accompanied in the exam room by a miniature one year-old, the daughter of one of her daughters.

Pretty used to have another daughter, but she died.

“This one won’t grow,” Pretty said, nodding toward her grandchild, who wore the clothes of a 6 month old.

For you newer readers, there are a lot of undersized kids around here.

“Her mother is afraid that the baby might have HIV.” Pretty shifted her weight slightly. “She will not test her.”

“She recently had thrush too,” Pretty continued, again nodding toward the child.

Thrush is not normal in a healthy one year-old.

The kid was starting to figure out that she was the topic of conversation, and the corners of her mouth sank symmetrically toward her chin, indicating that she would cry in approximately ten seconds.

She looked up at me.

Nine seconds.

Her big brown eyes became accusatory and frightened. (“What the heck did I do?” I wondered.)

Eight seconds.

I grabbed a cute little book with a doggy on it, a book in which the doggy actually has fur you can touch, and within its pages there are several other textures for the illiterate but tactile child.
Seven seconds.

She glanced at the book.

Six seconds.

She pushed it away.

Five.

With my other hand, I grabbed a bright orange, oversized leggo, and offered it.

Four.

She glanced at it.

Three seconds.

She pushed it away.

Two.

She inhaled deeply and looked fearfully at me, as if I were evil incarnate. (She had apparently forgotten about my heartfelt peace offerings, or perhaps she did not like furry puppies and the color orange.)

One.

She exhaled, and with it came the screech that I no longer really hear because, in my line of work, I hear it so doggone much.

Her large, dry, suspicious eyes were now puffy, wet and pitiful.

I was reminded why I even bother trying to [futilely] prevent a frowning one year-old from crying ten second later: they just look so darn pathetic when they weep.

Cute, but pathetic.

Pretty and I began to discuss her reasons for coming into the clinic. (It was the 64 year-old who was the actual patient, not the screeching, frightened, pitiful yearling.)

With the doctor’s spotlight pointed safely elsewhere, the baby eventually calmed down and started fiddling with the fake fur on the cover of the book. She even reached for a leggo (a big, bright pink one) and alternated between sucking on it and banging it on the wall. Each collision left a few small specks of saliva behind.

Apparently she preferred pink to orange.

Pretty has been on ARVs since 2003. When she started, her CD4 count was in the sixties. The ARVs had quintupled that number.

“I am very well on these medicines,” she said when I asked her how she was doing.

I gave her a prescription for more of the medicines that were keeping her very well and stood up to escort her to the pharmacy.

“Does your daughter know her status?” I asked.

“She is scared.”

“Can you talk to her?”

“I can.”

“If she is positive, we can offer her very good medicine.”

“I know.”

“If the baby is positive, the medicines will help the baby grow and help her body fight off the thrush.”

“I know.”

“Will you invite her to come with you next time?”

“I will.”

As they walked down the hall, the baby watched me—the scary physician—move farther and farther away.

I was no longer a threat.

She was no longer frowning, no longer afraid.

I am afraid that she will not be back.

"The Replacement Feeds Cooking Show" - What I was up to last Saturday, Part 2

(continued from Part 1)

“So?” I asked Eileen as I stepped out of my car. “Why am I here?”

As I mentioned in my previous entry on th 17th of March, I had been recruited with some haste to drive a half hour from the Baylor clinic to the “set” where an informational video on infant nutrition was being shot.

In so many words, I had been told that my services were to be critical to the success of the film, that I was the only one for the job.

“Come have a look.” Eileen said, leading me to the large tree beneath which scene one was being filmed.

There were about a dozen people beneath the tree, and all attention was focused on a reed mat at the base of the trunk. On the mat there were two women in traditional Swazi clothing. I recognized them.

Cameras were rolling, and the actors were speaking animatedly in SiSwati.

Filming scene 1.

The dialogue (borrowed from the English version of the script) was as follows:

“Yes, I have been trying to introduce solids foods, but I am finding that Mfana doesn’t always like to eat the things I give him.”

“Oh, there are easy ways to make nice healthy tasty meals for Mfana. This way he will grow nicely…Let’s go into edladleni [i.e. hut] and I can show you how to make a good meal for your baby…”

“Yes, I would like to learn.”

“Cut!”

The voice came from the film’s director, who was looking intently into a TV screen. The screen had a parasol and cardboard shades taped around it to block out the midday glare.

“Nice job, Eunice. Well done, Nomsa. Do you want tea?” One of the film crew said.

The actresses politely accepted the offer for tea, though I suspect what they wanted more than anything was an excuse to sit for some moments indoors. Their garments, though both attractive and undeniably Swazi, appeared heavy, and the Saturday sun was set to broil.

Me and the actors.

If they minded the heat, they did not say, for Eunice and Nomsa are not complainers. Nor are they actually actors. Their real job is to interpret for the English-speaking doctors at the Baylor clinic. They do their job very well, and always without complaint.

Today, they were starring in a film about infant nutrition, and they had just completed the first scene. The third member of the three-person cast (playing the infant Mfana) was still in his dressing room.

The name of the film is the “Replacement Feeds Cooking Show.” It is being produced to address the complex problem of safely feeding young babies in resource-limited settings like Swaziland.

Failure to do this, of course, can lead to malnutrition and another preventable death. As I have discussed in recent entries, this is all too common in this part of the world.

The film is sort of an “infant nutrition 101”, addressing the timely introduction of solid foods, water hygiene and safety, appropriate food choices (see photos below), cup feeding, etc.

Healthy, calorie-dense, vitamin rich foods.

More healthy, calorie-dense, vitamin rich foods.

The final product, which is likely to end up approximately 15 minutes long after editing, was undertaken by a group of Waterford students in collaboration with two Baylor physicians—Eileen Birmingham and Julia Kim.

Waterford is short for “Waterford Kamhlaba United World College of Southern Africa”. It is a private international school linked with other United World Colleges (in Italy, Venezeula, New Mexico, Singapore, Norway, India, Hong Kong, etc.). The students participating in the project were similarly diverse, self-identifying as Portuguese-Angolan-Mozambican, Mexican-American, Kenyan, Kenyan-American, Ugandan-Rwandanese, North American, Israeli, Zimbabwean, etc.

The cast and crew.

They were part of the two-year pre-university international baccalaureate program, and they were an organized bunch. Not only had they printed digital images of each scene’s layout for the shoot (see photo), they all had special Hollywood-esque titles, from “director” to “sound technician” to “set designer” to “producer” to “lighting specialist.”

They left little to chance.

Illustrated script.

Everyone in position for scene 2 (around the edladleni).

As the film crew calculatedly mulled about and the actors had a tea break, I asked Eileen again. “So, why am I here?”

“Well…”

I was getting a tad suspicious.

“…We need you to barbeque the meat for lunch.”

Okay, so grilling meat is not an emergency, per se. It never has been and never will be. I would have pointed this out to Eileen, but I was actually flattered that she associated me with high-quality barbequing. Moreover, I am a Texan, and I like to barbeque, especially under extreme conditions.

These were extreme conditions. The sun was a heat lamp. The grill was a mere three square feet and missing two legs. The “pit” where I was to barbeque was a concrete foundation for a future residence of some kind. There was meat for 20-30 people in the refrigerator, and lunch was in less than an hour.

It was the perfect challenge for a guy like me. That is, it was an ideal opportunity to prove to myself that the three decades of watching my father feed millions of family members with his XXL smoker and XXXL grill was not wasted, that I had not fallen too far from the tree…the exotic, towering masterful-cooker-of-meat tree, that is.

Heck, now that I have had time to reflect on it, maybe it was sort of an emergency. No nutrition video can reach its full potential if those involved in its production miss lunch.

In addition to cooking, I was also quite interested in the filming of the cooking show, and was looking forward to observing after completing my official duties. After all, a film of this sort, if carefully put together, is an important and effective tool for grassroots education.

Besides, its well-planned creation promised to be quite a spectacle in its own right.

In short, the film was the sort of thing that I felt proud to be involved in, even if my involvement was peripheral and involved baking in the sun while roasting in the heat of a nearby fire.

“I am going to need some sweat-proof sunscreen,” I told Eileen.

As you can see from the photograph, I got the job done.

Me "getting the job done".

The actors and film crew were running a bit behind schedule but eventually had lunch. They seemed to like it, which made me happy.

I read through the script of “Replacement Feeds Cooking Show” as the group ate. The final line of the film is as follows:

“Feeding babies is like building a traditional hut. If you want it to be strong enough to protect you from the storm you have to build it with the best material and tie it tightly even if it will take you longer. In other words, you should be patient!”

--

Even more than grilling meat, my father loves to smoke it. He cooks it so slow that, when he finishes, you can cut it with a fork.

It takes several days to do this well.

While I am not sure that I inherited my father’s talent for grilling and smoking, I know why he likes doing it.

He enjoys ensuring that people are well fed.

The cast in the edladleni .

The modernization of the cash cow, Swazi style

I like this billboard, which I saw on my way down to the nutrition video shoot Saturday. (Part 2 of that story will be posted shortly.)

It is very dry here these days - An update on my garden

The dry weather conditions here in Swaziland (see previous post titled “To make matters worse”) have taken their toll on my garden. Despite frequent watering, I am afraid there more shriveling than blooming going on. As you can see from the photos below, the peppers and basil really don’t mind the water deprivation. The squash and tomato plants have lost their leaves and have left but a few lonely edibles behind.

Ryan's hot peppers.

Ryan's bell peppers.

Ryan's basil.

Ryan's tomatoes.

Ryan's butternut.

While I can do without a bumper crop, I worry for the 80% of Swazis who are communal farmers and for those farming without irrigation (the vast majority as well).

As you can see from the photo of my sweet corn, even with some watering the stalks look unhappy. I have yet to see how the cobs are holding up.

Ryan's unhappy corn.

Unfortunately for the rest of the country, Mbabane tends to see more precipitation than the low-lying regions. I came across this quote from the agricultural field officer in the central industrial town of Manzini, several hundred meters below Mbabane in the drier valley Ezulwini Valley: “The rains stopped just as the maize crops were reaching the critical stage in their growth, where they develop tassels and the cobs enlarge.”

It is very dry here these days.

Whispers and averted eyes – What I was up to today, Part 1

Mural in Baylor COE waiting room.

Teenager with HIV are teenagers. They are bold but timid, awkward but desperately trying not to look it, and the boys and girls and preoccupied with the girls and boys, respectively.

Every month, the Baylor clinic here in Swaziland hosts a Saturday morning adolescent support group meeting. Today, I dropped by the clinic to check it out.

When I arrived, the group was gathered in the clinic’s kitchen having baloney sandwiches.

I am not a big boloney eater and those that were seemed to be enjoying themselves, so I went upstairs to check my email.

After the white bread and breakfast-time lunch meat were consumed, the group transitioned to the conference room, where the meeting started with a song, as Swazi meetings usually do. (I interpret the tradition as a polite way to say, “If you can hear us but are not singing, then you are late for the meeting so follow the voices until you are where you are supposed to be.”)

I was actually engrossed in email and running late myself when I heard the singing. I quickly clicked the ‘send’ button on my message. (Summary of message: “Dear so and so. Thank you for your email ridiculing me for my alma mater’s first round loss in the NCAA tourney. Even if Duke did lose, Texas (my other alma mater) did not, and besides, I am handily winning my ESPN Tournament Challenge March Madness bracket. Moreover, you can’t even dribble with your left hand. Love from Swaziland, Ryan”)

After my e-retort was safely on its way northwest, I scurried down the hall and sang the last verse of the song (or rather hummed it, as it was not a song that I knew). The music ended and the chorus of teens sat.

The chairs in the room were arranged in a large circle.

My eyes scanned the attendants. There were about two dozen of them, their age range approximately 10 to 18 years old. Most slouched in their seats (a habit I also picked up during puberty and have yet to shake), and nearly all had an arm slung over the back of his/her chair or sat with arms crossed, fitting, time-tested accompaniments to poor posture.

One young man caught my eye, for sat up straight on the edge of his seat, his hips at a perfect right angle. His hands were at his side. There was eagerness in his facial expression. Something was clearly on his mind, though I was never to learn what that thing was, for I never heard him speak.

Like most in the room, he was small for an adolescent. (Fighting HIV burns a lot of calories, and these children had been burning calories in this manner for a lifetime.)

Gugu, one of our clinic’s triage nurses, welcomed everyone and asked who in the group was there for the first time.

Four raised their hands.

The four were asked to introduce themselves, which they did in turn, each in a barely audible, whispery voice with eyes fixated on the ground in front of them. When Gugu would ask them to repeat themselves louder, they would repeat themselves, but softer still. As their voices sank, their gazes would sink also (nearing the shoes), and their faces would blossom (or perhaps wither) with self-awareness.

As I watched this, I wondered why they were so reluctant to speak.

Then, to the best of my ability, I imagined myself in their shoes, addressing a room of HIV positive peers for the first time, in doing so disclosing that they too were HIV positive, that they too had a lifelong, secret affliction.

My conclusion: Sharing a carefully kept, mortal secret with a group might indeed be easier in a whisper while staring at one’s shoes.

During introductions, a fifth first-timer briskly walked in. I noticed a cotton swab in her right ear as she passed.

Ear infections with persistent drainage are common in immunnosuppressed children. I wondered if there was pus behind the cotton.

The final newbie whispered her name (“Busi Dlamini”), age (“twelve”) and school level (too soft to hear).

After introductions, Nosipho, our clinic’s tireless social worker, passed out the meeting agenda. The first agenda item, she explained, was to reflect on last month’s “Voice of the Church” radio broadcast. (A few of the teens had been interviewed on nationwide radio about their status and why they sought treatment.)

Though the program (one of Swaziland’s most popular) was in SiSwati, I had been told that, when one of the teenagers was asked on the program why he wanted to know his HIV status and start medicines, he stated, “Because I was sick. Now I know I am positive. Now I am on treatment. Now I am better.”

Nosipho then pointed out the second item on the agenda: Fundraising, namely ideas about fundraising and how to spend any funds that are raised. The words “jumble sale” appeared in this section of the written agenda, which I later learned is the name for a “garage sale” or “yard sale” in a place where garages and designated yards are uncommon. (In any case, yards in Africa are called gardens.)

The final item on the mornings docket was “Drawing.” Nosipho explained that, if the teens are able to create some interesting, colorful illustrations, the drawings could be used in future HIV media campaigns or other HIV-related health projects, such as the ongoing effort in the clinic to package condoms in small, illustrated paper packets to make them more appealing to potential, um, family planners.

I looked forward to this agenda item, hoping that colored markers and paper might uncover the thoughts and ideas behind the whispers and averted eyes.

Alas, at that instant my cell phone rang, and I learned of an “emergency” that would cut my attendance of the adolescent meeting tragically short. About a half hour’s drive from the clinic, two of my colleagues—Eileen Birmingham and Juli Kim—were helping a group of high school students film a nutrition video to educate Swazi moms about infant feeding.

“We need you down here,” Eileen said.

“Do you want me to act in the video?” I asked excitedly.

“No no no, Ryan.”

“Technical support?”

“No.”

“Do you want me to edit the script?”

“Nope.”

“What, then?”

“It is something that you are good at.”

Now I was really confused.

“What, then?”

“Come on down. We really do need you.”

“Okay.”

I asked a colleague at the teen meeting to take notes and drove down into the valley, past the Matsapha International Airport, and to the homestead where the video was being shot.

Though I had looked forward to the teen meeting, and though I was suspicious that the “emergency” may not be terribly “emergent”, I was curious to see the filming of the nutrition video as well. (There is certainly a need for this sort of teaching tool in Swaziland, where preventable infant malnutrition and death are common.)

I pulled into the gravel driveway per the directions I had received, and saw the students filming under a shade tree in front of the house that had been appropriately described as “terracotta” in color.

I got out of the car, eager to know the nature of the “need” I was to meet.

Eileen approached the car.

“So?” I asked.

(To be continued…)

Enjoy the weekend, folks.

The internet has been too slow today to post large items, but I came across a link that summarizes some of BIPAI’s recent activity.

Baylor Pediatric AIDS Program Increases Number Of Children It Provides With Access To Antiretrovirals By One-Third

More to come soon, y’all.

-Ryan

Making matters worse: A news story about Swaziland's projected food shortages

ww.irinnews.org

For those who read my previous entries about severe malnutrition (Children should not starve to death, Improv and starvation, and Rounding with Dr. Akingbe.), you will not be surprised that Swaziland has problems with food security. But, you may be surprised to learn that we are currently bracing for possibility of the country’s worst food shortage in 25 years as a result of unusually dry weather over past months.

As reported in a recent article from the UN Office for the Coordination of Humanitarian Affairs, 2007 has brought Swaziland heavy winds, hailstorms and a scorching dry spell, but little water. While the dry Lowveld and Lubombo Plateau are accustomed to this type of abuse, this year the growing conditions for the entire country have been compromised.

The price of maize has already risen by 80% and will likely double before the May harvest.

The World Food Programme (WFP), which has supported a quarter of Swaziland's 1 million people with food assistance since 2002, plans to assess the impact of the dry spells on the national food supply in the weeks ahead.

Ben Nsibandze, Director of the National Disaster Relief Task Force, expects the impact to be huge, and predicts that maize will disappear from store shelves nationwide.

"Widespread food shortages will be experienced, particularly by the most vulnerable communities," he told a press conference.

Of course, no discussion of disaster and vulnerability can leave out the fact that, long before dry weather killed the crops, HIV killed a large fraction of Swaziland’s farmers.

Nobody knows this as well as Frank. The following quote ends the article: "I am the only able-bodied man in my family. I have to look after my two brothers' fields now…The crops are so scarce this year, it's not worth it. The crows will get what little is left."

For the entire article, please see the following link: "Maize prices shoot up as food shortages loom "

Cooking in - A dinner party idea from Swaziland

Photo by Brian Crompton.

If you put a small skillet on your coffee table and put a few millimeters of sugar cane liquor in it, it works sort of like an indoor smokeless barbeque pit. Portuguese sausage (less oozy) works best. They do this here in some of the "Swazi-Portuguese-Mozambican" fusion restaurants, so I thought I'd try it out. It is fun, tastes good, and is not all that dangerous.

Pretty pictures of Mozambique

It is nice to have friends that are willing to drop by for a visit. It is especially nice when they take a day-long plane ride to do so. It is nicer still when they bring high-dollar cameras with zoom lenses, polarized this and that, platinum tripods, remote controls, etc. I traveled with three such well-equipped gentlemen--Brian Crompton, Chuck Freeman, and Dave Wanderman--last week. I cannot take credit for the photos below (taken by Brian Crompton), but I can take credit for the dull captions. These pics were taken during a recent road trip to and Mozambique. Below these, I have posted some from Kruger National Park and Blyde River Canyon.


Moon over Maputo Bay.


Inhaca island, Mozambique.

Pretty pictures of wild animals

Giraffe.


White rhinos.


Cape buffaloes.


Elephant.

Pretty pictures of wild animals, part 2

Lion.


Hippo.

Croc.

Striped horses.

Pretty pictures of falling water

Ryan, Chuck, Dave, Brian and Lisbon Falls (92 meters), Blyde River Canyon, South Africa.


Berlin Falls (45 meters), Blyde River Canyon.


Mac-mac falls (65 meters) , Blyde River Canyon


Pinnacle Falls and Ryan (5' 10.5"...when standing, and at least 6 feet tall on tip-toes)

For sale: 3.5 billion condoms - A news story about India's condom vending machines

img.alibaba.com

I am not particularly impressed by the marketing strategy (see pictured vending machine above), but I am most impressed by the scale of ongoing HIV prevention strategies in India.

Check out the following story (as summarized by me), posted on www.medicalnewstoday.com.

"India To Increase Condom Vending Machines Fivefold As Part Of HIV Prevention Campaign"

India's National AIDS Control Organization plans to increase the number of condom vending machines in the country by fivefold, effectively raising the number of condom distribution outlets from 600,000 to three million and raising the number of distributed condoms from 1.6 billion to 3.5 billion over the next three years.

Wow.

See unabridged story for more.

The Pediatric AIDS Corps prepares for its second year - Recent media

Check out Leigh Hopper's Houston Chronicle article below for an update on the PAC.

"AIDS Corps' boosts number of kids getting care"

"Living with Slim" and "The Blood of Yingzhou District" - Two pediatric HIV documentaries worth a peek

In the documentary"Living with Slim", seven Malawian single- and double-orphaned children talk about what it’s like to be HIV positive and about their dreams for the future.

Conservatively, there are 550,000 AIDS orphans in Malawi. (www.avert.org)

(Copies of "Slim" available for $25 from Sam Kauffmann (samfilmtv@yahoo.com).)

"The Blood of Yingzhou District", a film about Chinese AIDS orphans, won the 2007 Academy Award for best documentary short film. The 39-minute film records the lives of a group of HIV-positive children whose parents died from AIDS-related causes.

Conservatively, there are 76,000 AIDS orphans in China, and the number will increase to 260,000 by 2010.

Swaziland, where I live, has a million inhabitants and 70,000 orphans. In 2010, there will be around 120,000. (See my Nov 2006 entry, "Parentless children with nothing to lose" for more on this.)

By the way, if you wish to support families that feed and house one or more Swazi orphans, check out the Swazi nonprofit Young Heroes. I know the folks that run it, and they apply all donations at the household level, where they are carefully monitored.

Please do give if you are so inclined.

Revenge of the nerds - Two news stories about how scientists are keeping pace with HIV

I tell my patients that, if they always take their medicines on schedule, they can live long, healthy lives. I tell them this because it is true.

Since the word "always" cannot actually be applied to normal human behavior (especially that of children), doses are inevitably missed, and following continued imperfect dosing comes resistance.

Viral resistance to ARVs, of course, means a return to sickness and a shortened life.

Fortunately, human beings are at least as innovative as they are inconsistent, and scientists continue to find new ways to keep pace with the ever-evolving retrovirus.

Daily, I allow myself to hope that our clinic's youngest patients will die of that vague syndrome we call "old age" rather than acquired immunodeficiency syndrome.

When I come across news stories like the two cited below, I am reassured that such hope is not unfounded.

The first story discusses two new classes of drugs --CCR5 and integrase inhibitors--which have been found to control the viral loads of HIV-positive people with drug resistance. The second discusses a compound called cyclotriazadisulfonamide (CADA), which promises to inhibit replication of HIV by eliminating the "door handle" by which receptor molecules on the surface of a white blood cell normally grab HIV.

Complicated, hopeful stuff, no?

Swazi children should not starve to death – A visit to Good Sheppard Hospital’s malnutrition ward

Malnourished child, MGH pediatric ward.

“You need to be very pushy, so they call it…Pushy, but not by force. Pushy by persuasion.”

We nodded and a few of the women exchanged knowing glances.

“You may meet resistance along the way…Whatever is good will stand. Don’t give up…okay?...Don’t give up.”

These were among the last words that Dr. Joyce told us before we got back in our car and returned to Mbabane.

The five women at the table with me were at the front and center of Swaziland’s battle against malnutrition in children. They represented the two largest pediatric referral centers in the country—Mbabane Government Hospital (MGH, which I have written about before) and Good Sheppard Hospital (GSH).

Early that morning, four of the five had traveled the ~80 kilometers from MGH to GSH to share ideas about inpatient malnutrition. The fifth, Dr. Joyce, was waiting for us when we arrived.

As for me, I was the driver. A necessary sixth.

The roads between Mbabane and Siteki, though not perfect, are quite good, but one does have to mind the occasional hole, cow, goat, and oncoming traffic. (Be especially aware of older cows and minibuses, as they seem to categorically prefer death to yielding.)

Nurse Happiness (MGH’s feeding program coordinator) sat in the front seat. “I like fast cars,” she said as we pulled out of the MGH parking lot. My 1997 Opel Astra station wagon is not particularly fast, but I said, “Me too!” just for fun.

Sister Florence (MGH’s head nurse), who sat in back, took the opportunity to point out that she does not like fast cars. She also politely told me that she preferred that I keep both hands on the wheel. She was the senior MGH staff person present, so I graciously complied.

MGH’s nutritionist, Tandi, did not comment on my driving, but she probably preferred fast to slow, for she was among the most excited to see Good Sheppard’s feeding program.

“I am always afraid to come in to work on Monday,” I heard Tandi say from the back seat, “I do not like worrying how many children died over the weekend.”

At MGH, many children die over the weekend. Weekend or not, most children admitted to MGH for severe malnutrition die during their hospital stay.

This should not happen, and is a sad state of affairs.

“How many children are admitted to MGH for malnutrition?” Eileen asked.

“At least half,” Tandi responded. This week, over 30 of the total 60 hospitalized children are very malnourished.”

Eileen was the final passenger. She is a fellow UCSF-trained pediatrician and Baylor Pediatric AIDS Corps member with a long-standing interest in nutrition. Because so few starving children (many referred from our clinic) were recovering, she had organized the trip as a sort of fact-finding, idea-sharing venture. The goal was simple: to prevent unnecessary dying.

That morning, to thank me for offering to drive, Eileen had had generously bought me a café latte and loaned me a recent copy of the New Yorker. Both are incredibly hard to come by in Swaziland, so I did not turn these offerings down.

The truth is that they were entirely unnecessary. It was to be one of the most rewarding days I have had so far this year.

--

Siteki, the town where GSH is situated, rests on a small ridge overlooking the “lowveldt” of Swaziland, a few hundred meters lower in elevation than the mountain-perched, relatively temperate capital city of Mbabane, where I live. The lowveldt is a sweltering place, a flat, arid place. A parched place.

A good place for a carefully managed malnutrition program.

We arrived at GSH safely, thanks in part to the continuous “support” of several well-meaning back-seat drivers. While most of the supporters used words like “caution”, “whoa”, and “look out,” Happiness just repeated the word “faster.”

Eileen mostly just laughed, which she does frequently and most genuinely.

Once on foot, we found our way to the pediatric ward. Because we had made good time, Dr. Joyce had not yet started malnutrition rounds.

“You are here just in time,” Dr. Joyce said. Happiness and I gave each other a high five.

Dr. Joyce is a distinguished-looking woman who obviously enjoys her work. Her hair is neat, her white coat pressed, her presence commanding and her demeanor that of a well-prepared teacher who has much to teach.

In addition to one station wagon full of visitors, her audience consisted of a nurse, two nursing students, a medical student (from the US), and several mothers who listened in as she reviewed the WHO malnutrition protocols with us.

Rounding with Dr. Joyce

Dr. Joyce has been at GSH for about six months. She had worked in several African countries and had run several feeding programs. She is from Zimbabwe, where her husband still lives. She often makes the 12 hour drive to see him over a long weekend.

When she arrived at GSH, the feeding program was not unlike ours in Mbabane. It needed help.

During rounds, Dr. Joyce reviewed the diagnostic criteria for severe malnutrition, the three WHO phases for treating severe malnutrition, and the logistics of feeding in a busy pediatric ward with a limited budget. We then saw each of the ~20 patients, in turn.

After each patient, Dr. Joyce had the endearing habit of making a sweeping but poignant statement, as if she had an internalized list of pithy malnutrition maxims and was awarding us for our attention by letting one slip out every so often.

After examining the first child, a gaunt three year-old with too many angles and not enough curves, she looked up and said, “When treating malnutrition, no shortcuts.”

She moved over to a child with too many curves and not enough angles, the swollen physique of kwashiorkor, or protein malnutrition. “The swollen tissues are getting better,” she told the mom as she was completing her brief exam note. “Well done.”

She paused, turned to us, and, as she shifted to the next patient, said, “Having little to work with doesn’t stop us from doing the right thing.”

Next patient.

“This does not require anything complicated.”

Next patient.

“If the mother’s do not want to work with you, you will not succeed.”

Next patient.

“If the child has HIV, fine. Put them on treatment…but always keep feeding them.”

Next patient.

“When mom’s see their babies actually getting better, they will be willing to stay.”

Next patient.

“You yourself need to be interested, and the rest of them will follow suit.”

Next patient.

Dr. Joyce pointed at two mothers discussing how to hold the baby’s cup when feeding.

“See, the mothers encourage each other. ‘Look at this milk,’ they often say. ‘It’s wonder-milk.’

In response to this, Nurse Happiness chuckled.

Dr. Joyce looked up at her.

“It’s just that I am happy to know that,” Happiness said by way of an explanation.

I chuckled too, happy that Happiness was happy.

Dr. Joyce continued, “On our malnutrition ward, mothers and malnourished children are grouped in the same section of the hospital to encourage them to talk and learn from one another.”

Happiness vigorously scribbled notes, still smiling. (MGH does not group mothers and malnourished children in the same section.)

Once the patients were all seen, we then followed Dr. Joyce from the malnutrition ward to the feeding station 10 meters away. The feeding station consists of a small table, two bowls and four buckets (three with different types of formula and one with oral rehydration solution). Above the table there was a list that reminded each mother which of the color-coded buckets they were supposed to take milk from. Indeed, this was not complicated.

GSH feeding station

As a group, the children in the feeding program at GSH require a total of 40L of formula daily, on average.

The homemade formula costs about a dollar per liter, and is prepared in the kitchen, a few steps from the feeding station.

The kitchen was the final stop on our tour.

It was a small room, similar to a kitchen in a typical US budget apartment. It contained one sink, a counter top, an electric stove with 2 burners, a few utensils, a measuring cup, 2-3 pots and bowls, a time-keeping device, and the ingredients for the milk-based formula.

GSH kitchen.

Dr Joyce explained that the kitchen is run by orderlies who were trained to mix the milk appropriately, and who in turn train others as staffing needs change. The orderly on duty demonstrated to our group how to mix the milk following the WHO recipe. The milk is made round-the-clock and the kitchen is not linked to the hospital’s primary meal service.

Kitchen tour.

“You need to have your own kitchen,” Dr. Joyce said. Sister Florence explained that MGH did not have a kitchen for making formula, and that all formula came from the hospital’s main kitchen.

“If you wait for the [hospital] meal kitchen, tough luck.” Dr. Joyce responded. “They will make it if and when they want.”

Happiness, Florence, and Thembi knew this all to well. Children admitted to MGH frequently miss meals. The milk simply never shows up.

Eileen was busy taking photos of the GSH kitchen, for she has plans to help build a kitchen in MGH’s Ward 8. The room is already picked out, and Happiness, Florence, and Thembi’s are thrilled.

“I think we should tile the floors in the new kitchen,” she told Thembi between photographs. “It makes it look so clean.”

“We must,” agreed Florence. “But”, she said, examining the floor, “we much find the kind that fit together nicely, so that dirt does not get stuck in between.”

"We should go shopping tomorrow," Eileen said. "One of the doctors already said we could borrow his car."

Eileen, you see, is quite a planner.

The tour ended, and Eileen bought us all cold soft drinks. They did not stock juice (too expensive) and were out of brand-name Coca Cola, so I ordered a carbonated passion fruit-flavored beverage. It was vivid orange, similar in color to those little floaties that kids wear in swimming pools, the ones that fit snugly around their upper arms and keep their heads safely above water.

It tasted good, but not so much taste like passion fruit, just as watermelon-flavored gum does not actually taste like watermelon.

Still, like Swaziland’s parched lowveldt, I was hot and thirsty.

The cold drink got the job done.

Child at entrance of GSH ward.