To run and play – Introducing Khulekane (1 of 10)

Khulekane and his gogo.

[This is the first in a series of ten patient intros. No particular order or format. Just a few facts about a few of the children that come to our clinic for care.]

Khulekane (pictured above) was one of my patients today.

He was first seen here Feb 29th, 2007 when he tested positive after his gogo (i.e. grandmother) thought that he appeared sickly.

He is 10 years old and lives in Mnyokane, a small village north of here, about an hour and a half or so by public transport.

Khulekane likes to play football (the kind played with the feet, of course).

His favorite food is “rice and meat.”

He comes across as a shy boy, but he isn’t one. Whatever pretense of timidity dissolved the instant that I gave him a printed copy of the above photo.

Now we are buddies.

Khulekane is not on ARVs yet, but will need them soon. His last CD4 was 392. We are checking his CD4 next month to see if it has fallen any lower.

From a medical standpoint, Khulekane is doing quite well. He was almost certainly infected with HIV at birth, but despite a full decade of HIV infection and its poisonous effects on the immune system, he still has enough CD4 cells to ward off most infections and kick a soccer ball around with his peers.

His swollen parotid glands, anemia, and minimal recent weight gain offer hints that his body will not keep the virus at bay forever.

I asked Khulekane what he wants to be when he grows up, and he said he wants to be a nurse.

His gogo quickly confirmed this by saying, “Yes, he does.” She then paused and smiled, adding, “But for now he likes to run and play.”

One hundred and one Swaziland destinations - #1: "The Cuddle Puddle"

This is where I spent my early morning today. (That's me in the back left corner, I believe.) It is essentially a spring-fed swimming pool.

The water is warm enough to swim laps, and probably too warm to cuddle in any meaningful way.

I wouldn’t know.

Why I love my job – Quote 10 of 10

www.worldhope.ca

“The number of HIV-positive people in developing countries with access to antiretroviral therapy increased 54% to two million people in 2006.” -UNAIDS

BIPAI was a major contributor to this number, especially among children.

Save your pats on the back for later; according to a report released last Tuesday by UNAIDS (where the above excerpt originated), 380,000 children died of AIDS-related illnesses in 2006.

Three hundred and eighty thousand...

...due to a lack of access to existing drugs.

A few pills or syrup teaspoons a day equals undead kids, healthy kids.

Smiling, playing kids.

--

Only 15% of the 780,000 children in need of antiretroviral drugs had access to treatment by the end of last year.

Only 4% of HIV-positive children received the antibiotic co-trimoxazole, recommended by WHO for HIV-positive children and infants who contracted the virus from their mothers during birth.

Children account for 14% of those in need of antiretroviral treatment in the region but only 6% are on such treatment regimens, according to the above report.

Because numbers such as these tend to underwhelm or overwhelm (for being too abstract or too big, respectively), I am going to begin a series of mini-biographies of some of these children tomorrow.

For abstract of report cited above: Antiretroviral Therapy Access Increases In Developing Countries, Hundreds Of Thousands Of Child Deaths Preventable, U.N. Report Says

Why I love my job - Quote 9 of 10

The first child to receive ARVs at Lomahasha clinic.

“The first pediatric patients on ARVs have been rolled out and were seen on site by the outreach team and a nurse of Lomahasha clinic...It was a very special moment, because Lomahasha is the first site for roll out and is hopefully serving [as an example] for many other clinics that will follow in the future.”


This is a segment from an email from Helga Loeffler, a colleague of mine here in Swaziland.


We are working toward the decentralization of pediatric HIV care throughout Swaziland, and the Lomahasha clinic, previously ill-equipped for such care, is now dispensing ARVs to children.


A 'special moment', indeed.

Lex talionis - Recent human rights media

See link below for a bit of heavy reading from "IRIN Africa", the UN Office for the Coordination of Humanitarian Affairs. As often is the case with issues involving gender violence, retribution, and death, the material is as disturbing as it is weighty.


SWAZILAND: AIDS activists call for death penalty for HIV infection by rape

The mysterious noise – An [auditory] patient encounter

[Disclaimer/warning: This is a long entry. Sorry. Scroll down for easier-to-read, bite-sized excerpts...]

I had never heard a noise quite like it before.

I was outside the waiting room in the parking lot of of of Swaziland’s many Public Health Units (PHUs), and it came from inside.

I could tell that the mysterious noise was the whine of a crying child, probably around two years of age.

The age estimate was based on the easy-to-recognize monotone quality of the cry, the type that betrays the fact that the child is actually not too terribly upset, but does not wish to admit it. Such lack of intonation is uncommon in a much younger baby, who typically cries sincerely, if not passionately, for want of something. The really young ones hit several tonal variations and several impressive notes. They throw in frequent crescendos. If truly peeved off, they sometimes will even naturally soften into a decrescendo before really blasting off.

Quite an intense, operatic communication style, especially for such a small creature.

But, as we all know, babies eventually develop personality and learn that they can pretend that they sincerely need something, and adults scurry here and there to find out what it is.

During my first year of pediatrics training, I used to fall for that.

Then, in a moment of on-call late night clarity, I realized that these mimickers had what card players call a “tell”, basically an unwitting giveaway that one is bluffing.

If you identify the tell, your opponent is busted.

For me, this was one of the primary epiphanies of my medical training (#7, actually). The other six are:
(1) It is easier to say “I don’t know” than to make an educated guess and be wrong.
(2) It is easier to sleep in really baggy scrubs than the more stylish, “fitted” ones.
(3) Circumcisions do not hurt newborns [that much] if they are sucking on a pacifier dipped in sugar water.
(4) If you learn who to ask for help and when, it is possible to practice very good medicine under most any circumstance.
(5) San Francisco does actually have a reasonable barbeque place—Big Nate’s—that delivers to most area hospitals.
(6) Kids pee, poop and reason with an unpredictable (in)discretion.

Though I do not want to give up too many trade secrets willy-nilly (for surely someday I can sell them), those were freebies. I will even elaborate on the seventh:
(7) When a 1½-2 year-old wants to put on a demonstration of being upset, they tend to choose a note, often in a minor key (D and E flat are favorites) and they stick with it, interrupting the din only to breathe.

Oh, another thing. A fake cry is usually slightly nasal, for it takes less effort and breath than making a proper, back-of-the-throat, cry.

Go ahead. Try it.

In any case, I heard this noise when walking into the crowded PHU waiting room

The purpose of our visit was PMTCT.

PMTCT stands for “prevention of maternal to child transmission [of HIV],” and, if used successfully as a public health strategy, can put me out of a job.

Though I would like nothing more than to end my pediatric HIV career early, there is no danger of that happening any time too soon, as a pitiful ~10% of HIV+ pregnant mothers receive PMTCT drugs in Sub-Saharan Africa.

Back to the main topic of this story: the ~2 year-old’s cry.

It was a D flat, more or less, mostly originating from the nostrils.

I had heard plenty of nose-heavy D flats, but this particular cry had something unique about it.

It was in staccato, as if the nearly two-year old were operating a low-frequency jack-hammer.

If that is hard to imagine, and you have been to an African bus station/combi stop, it was similar to the sound of an eager driver rhythmically abusing his horn to declare either “all aboard” or “get the hell out of my way”. (I was wandering around Mbabane’s bus ramp the other day in a futile search for a watch battery, and should probably dedicate an entire entry to that entropic parking lot, for it is rife with bloggable imagery and chaos.)

In any case, I initially thought the jack-hammering-horn-like-mystery noise might be the result of a mother firmly patting the back of a baby throwing a fake temper tantrum, but non-abusive back-patting should not knock the air from a toddler’s lungs.

My expectations mounted as I finally stepped in the door of the waiting area.

After my eyes adjusted to the indoor half-light, I scanned the room. Mothers and babies were everywhere. Babies were breastfeeding, a sleeping, and having diapers changed, mothers were breastfeeding, dozing, and changing diapers, and a handful of children, siblings I suppose, were jockeying for attention from their respective breastfeeding, dosing, diaper-swapping mothers.

When I at last tracked the cyptic honking sound, I was disappointed in myself.

I should have known.

Babies here, when are not eating, are with rare exception attached firmly to their mothers backs. This is especially the case in space-limited waiting rooms, in the interest of crowd-control.

When I was a pediatric resident, I completed an outpatient rotation in one of San Fransico’s more frou-frou private hospitals. Intrigued by the no-holds-barred buy-loads-of-stuff-for-my-baby culture of my patients’ parents, I did some research into the locally-marketed consumer goods for new mothers (and fathers).

One of the items I investigated was baby-carrying devices.

There are several models, ranging from ~USD$30-3 trillion. One can fancily strap a baby to his/her front, back, or side. The baby can face forward or backward. There are frills galore and several fashions, fabrics, patterns and colors to choose from. The “Baby Bjorn” seemed to be a West coast favorite. (It is a Swedish brand with a tradition of high quality baby-carrying since 1961.)

In Swaziland, the popular choice for the purpose of lugging babies is an old blanket or bath towel tied in a knot.

No doubt the Baby Bjorn comes with an instruction booklet, so here is one for the Swazi version: Imagine getting out of the shower and wrapping a towel around the waist, except wrap it a bit higher while bending forward, clothed, with a baby laying prone on the back. Ensure that the fabric is snug around the tike’s bum, and tie a simple but firm square knot in front.

The babies love it. If they do not, retie.

The baby making the mystery noise was tied in the manner described above, with a textbook wrap and knot.

Still, he cried.

I believe that he had just had his blood drawn, or maybe he had peed himself. Whatever the case, he had gotten over it but was still milking his audience for more attention.

Now for the punch line.

In an courageous but ineffective attempt to quiet the noisy strapped-in baby, the mom was actually jumping up and down.

Not just bending the knees, but really hopping. Approximately a 5cm vertical, I would say.

Each time she hit the floor, it knocked the air out of the child’s lungs.

Come to think of it, the impact itself may explain why the child continued to half-heartedly protest.

Or, maybe he liked it, and didn’t want her to stop.

In any case, for those of you wishing to invest in a device to carry a infant or toddler, if you can afford an up-scale high-tech San Francisco Pacific Heights Swedish model, feel free to invest.

If they have one with a suspension system, spend the extra dough.

Then, when your two-year old is pretending to cry, you can hop about all you want.

Religion, spousal abuse, and economic growth – Recent media

(www.irinnews.org)

If interested in the potential role of religion to fight HIV, the increasing (but reassuring) abuse statistics here in Swaziland, or the factors contributing to Swaziland’s lackluster 2% annual economic growth, have a look at the articles below.

Enjoy your weekend, y'all.

RAND Study Finds Religiosity Can Be An Important Tool In Preventing The Spread Of HIV-AIDS

Study Examines Effect Of Religious Belief On Spread Of HIV

SWAZILAND: Glad to see abuse figures rise

SWAZILAND: Economic decline as investors spurn kingdom

Only 33 candles – The Swazi king turns 39

Decorations (tri-colored banner and Swazi shield) over main road from Mbabane to Manzini

The controversial, polygamous king of Swaziland turned thirty-nine years old yesterday.

It was a national holiday. Our clinic was closed, as was almost everything else.

He celebrated the occasion in the town of Siteki, about 1.5 hours from here.

It is rumored to have been quite a celebration. (See news story links below.)

Though I was unable to make the trip to Siteki yesterday, the Baylor International Pediatric AIDS Initiative is here with the royal family’s blessing…

…and, as I am happy to be in Swaziland, I would like to take this opportunity to formally wish His Majesty a happy [belated] birthday.

May he have many, many more.

I extend the same wish to his impoverished, beleaguered countrymen, for the current collective healthy life expectancy for Swazi males is 33 years.

On my next birthday, I will be 32.

--

For more details on the royal birthday party, see the cover stories in today’s Swazi Times, including stories about the birthday cake itself and a young boy who gave the king "his last hen".
In the interest of, um, balanced reporting, I have also included the link to a story titled “Group slams King's R15m bash.”

(By the way, my birthday is June 15th.)

Fever and affection - A patient encounter

I reached out my hand to and told Njabulo to please feel better.

His small fingers were hot to the touch, well above the expected 37 degrees Celsius.

His face glistened as perspiration found its way to the surface.

I hoped that the sweat and ibuprofen he had just received would cool him down, for fevers are unpleasant, especially high ones.

Personally, I really don’t like having ‘em.

Njabulo did not seem to mind.

He reached out his clammy hand, squeezed my scaly-dry-from-too-much-between-patient-hand-washing hand, and held it for a few seconds.

He then took a step forward and casually rested both of his elbows on my lap.

He looked up at me intently, comfortably.

Everything about his demeanor suggested that he was actually my patient and friend of many years and I had somehow mistaken this for our first meeting.

Njabulo had been vomiting everything he put in his mouth for 24 hours, with the exception of some liquids and his ARVs.

I did not know for sure what was causing the ten-year old’s vomiting (a virus, bacteria, food poisoning of some kind, etc.) but as I watched him play with my stethoscope, listening into the left earpiece while tapping on the other end, I knew that he would probably recover quickly.

He was a resilient child. His CD4 had jumped from 394 to 1242 since starting ARVs and TB treatment mid-2006. There was light and energy in his eyes.

He smiled frequently.

I gave him some ORS packets and told his mom what to look out for, in case he got worse.

Njabulo seemed content to perch beside my chair indefinitely, but his mother grabbed one of his hands and pulled him toward the door. His other hand grabbed mine until both arms were taut, then he let my hand slip from his, and pulled the door closed behind him as he left.

I typed his clinic note into the computer and called the next patient.

Ryan's African tick bite fever - an update

For those who read the entry below about my recently-acquired African tick bite fever, I am happy to report that I slowly freeing myself from the disease’s achy, soporific grasp.

I have some tender lymph nodes in the region of the bite but, after a day off work yesterday and 48+ hours of doxycycline, the spring is back in my step and I am back seeing patients.

I decided to relent and share a photo of my infected bite site, or eschar (see below).

There are two reasons for this decision:
(1) The photo confirms the diagnosis and therefore [at least partially] validates my complaining and carrying on about the symptoms
(2) A few of you (especially those infectious disease specialist-types among you) have been requesting a picture.

Well, here you are:

I___________________________I = approx 1cm

For a description of what you are looking at, see the entry below titled "African arthropod + Tex-expat = African tick bite fever"

Another dead child – A patient encounter

“The child is not breathing.”

The nurse began giving mechanical breaths by squeezing a bag attached to an airtight mask that she held firmly around the child’s mouth and nose.

“What is the blood pressure?” I asked.

“The machine is not reading it.”

“Is there a pulse?”

“We can’t feel it.”

CPR was initiated.

I probed with the IV needle on the fleshy part of the arm opposite the elbow, hoping to see a flash of blood on the other end of the needle.

The arm was cool to the touch. It was an arm of more bone than flesh, the kind of arm that you see on documentaries about famine. The diameter of the elbow was far more than that of the biceps, which sagged over the humerus like an oversized nylon tubesock.

In short, it was the arm of a dying (if not dead) child.

IV fluids, dextrose, and antibiotics were placed beside me, even though all present knew that they would do little good.

“Please get Dr. Mahuma in case I cannot get this,” I said, knowing full well that an IV was useless in the absence of a beating heart.

Still no pulse.

I finally saw a drop of blood appear and advanced the plastic portion of the IV catheter into the child’s vein. The IV dripped very slowly, suggesting that it was in the wrong place or that there was little blood flow to pull the fluid along.

I feared the latter.

Dr Mahuma, an experienced South African colleague, walked in and surveyed the child.

“This child is not with us,” she stated.

Indeed, though we were giving breaths, several attempts to find a pulse were in vain, and a series of physicians listened intently to the chest and heard nothing.

I placed my right index and middle fingers over the child’s carotid artery and felt a periodic surge of blood in my fingertips. I placed my left hand on my own neck and confirmed that I was simply feeling the beating of my own heart.

It pumped vigorously, doing its part to help resuscitate the child.

Dr. Mahuma, Dr. Eileen, and Dr. Jo were also there, doing all they could and trying to decide what to do next.

The stuporous, vital-sign-less patient had never been to our clinic. By the time she arrived, unresponsive and stale, there was nothing we could do.

As I listened carefully over her chest for sounds of life, my eyes settled on the child belly.

The skin over her stomach looked like dried fruit. Her still chest protruded violently from the sunken abdomen, and her ribcage appeared old, almost mummified. There was little tissue.

My gaze wandered up to her face. Her eyes were rolled back, the whites still shiny and bright, like two crescent moons. Her mouth was slightly agape. A ivory-colored film coated her tongue and soft palate.

The child’s final facial expression told the story of a girl that had needed help for a long long time.

Now, the lifeless eyes and mouth seemed to ask, “Why not sooner?”

After some more artificial breaths and somber discussion, we declared the child dead.

She was ten years old.

--

Ventilators and intensive care unit beds are rare here. End-stage AIDS is not.

It is an abyss that few escape.

This is why we strive to test and treat HIV positive children as early as we can, so that they do not show up to our clinic stagnant, cold, pulseless, breathless, skin and bones.

When a child dies from a treatable disease, leaving wrinkled, empty skin, eyes half closed and lips unnaturally parted, the question “why not sooner?” is ours to answer.

The abyss that is unnecessarily claiming so many is our problem to solve.

African arthropod + Tex-expat = African tick bite fever

www.canr.uconn.edu

On the Tuesday after a long Easter weekend, I found two small ticks around my waist line and another under my left arm. (I would have preferred to have found chocolate eggs, or perhaps those plastic egg-shaped hollow contraptions where my parents would occasionally put jelly beans, chewing gum, or even a dollar bill.)

The ticks were roughly the size of coarsely ground pepper, and likely originated from the farm where I had just spent a pleasant holiday.

The speck-like arthropods seemed to be having a pleasant weekend as well, at least up to the time when the tweezers from my Swiss army knife interrupted their final blood-feast.

As long as I can remember, ticks have always loved me. Mosquitoes too. And biting flies. Until recently, I sort of took it as a compliment, for I assumed it meant that I had especially nutritious blood.

The fatigue and muscle aches began around eleven Saturday evening, along with a low-grade fever. One of the three bites, before just a tiny red bump, began to grow.

It is now 8mm or so, more raised, painful, red on the outside and black in the center, like a small inactive volcano (on Mars?) or a miniature stwarberry, molten chocolate Bundt cake.

Dermatologists might call the lesion 'papulovesicular', 'erethematous', 'ulcerated', or 'necrotic'.

The official name of this type of skin problem is 'eschar', from the Greek word 'eschara', meaning 'fireplace.' (Another apt image.)

I have not included a photo of my 'eschar' as it is just below my belly button and I am a bit shy about picture-taking near my naval.

My apologies.

The above image looks very similar...and less compromising.

For those of you who have been reading my blog, you have probably noticed that, besides thinking that I had TB after an ambiguous skin test early this year, I have not whined much about personal ailments.

That is not because I do not sometimes like to whine (why else keep a blog?), but rather because I have remained quite well.

I drink tap water, eat whatever is in front of me, spend much my time with coughing, sneezing, drooling, snotty children, and traipse/bike/run throughout the snake- and tick-ridden African countryside.

I have been fortunate enough to remain largely unscathed.

Well, I am scathed today.

The fever is persistent but responds well to Advil. 10-14 days of doxycycline should annihilate the "rickettsia" bacteria, the parasite within the ex-tick that is actually responsible for my symptoms.

It is sometimes difficult to know whether to blame the germ, the vector, or the irresistable, nutrient-rich victim in these matters.

Of the three potential culprits, at least I will live to tell about it, for African tick bite fever is rarely lethal.

Unfortunately, many vectors and germs that roam these parts are much deadlier.

Why I love my job - Quote 8 of 10

"But I have promises to keep. And miles to go before I sleep, And miles to go before I sleep."

Okay, so this is not actually a recent quote, but rather the end of a oft-cited 1923 Robert Frost poem titled, "Stopping by woods on a snowy evening."

There are no snowy evenings in Swaziland, but, as you can see below, there are many miles to go, indeed.

Not even a baker's dozen - Recent Swazi press

~88% of Swaziland's ~1,000,000 inhabitants, according to this article, do not know their HIV status. This leaves a lot of testing to be done, not to mention treatment. See full article here.

What a nice package you have – the art of popularizing rubbers

www.designinghope.org

Condoms are not terribly popular anywhere. Of course, Swaziland is no exception.

Swaziland does have an exceptionally high HIV prevalence, however. Still, barrier protection is not winning any popularity contests, no matter how potentially life-altering condomless romance is.

I am no condom historian, but I am sure that the French were involved.

They still are.

French designer Dessine l'Espoir, in conjunction with Designing Hope, a Paris-based HIV/AIDS advocacy group with an African focus, is preparing a “condom diffusion campaign” featuring prophylactics packaged in original printed boxes carrying a selection of artwork and awareness messages.

At present, free condoms are distributed in several African countries, but they are available only in featureless packets in boring metal boxes in dull places (bathrooms, administrative buildings, hospitals, border posts, etc).Here is the idea: if a condom is in original, groovy, trendy, artsy packaging, any passer-by in any public place can pretend to be taking the hip artwork home, not the contraception.

I am no social marketer and I am certainly not overwhelmingly hip, but I totally dig the premise.

Ten designer condom boxes have already been created and printed, and Designing Hope is distributing thousands of these in Swaziland and South Africa.

The photos below were taken in the Baylor COE conference room, where Sasson, a Designing Hope volunteer, was giving a workshop on how to assemble the fancy packages.

The Designing Hope website has several other photos that outdo my amateur images. (The French, I suppose, are generally more aesthetic than us Texans, not that I would want to generalize, for we Texans are are generally against generalizing.)

Two articles outlining the challenges of condom promotion in Swaziland are: "Students ignore safer sex practices, survey finds" (Nov, 2006) and "Resisting Condom Use As Aids Deaths Soar" (Dec, 2003).

Quotes from the second article include:

"Swazis dislike condoms. They are unSwazi."

"Condoms are useless...They cut down on pleasure. They are like eating a sweet with the wrapper on."

Wrapping something nicely, it seems, does not appeal to everybody.

--

For those among you who count barrier protection among your passions, you may also check out my previous entry about the "incredible melting condom" from December of last year. The post is titled "Thinking outside the condom box - A news story"

Oh, if you are really passionate and have a strong stomach, you can have a look at the summary of last year's article titled 'Nonscientific' Count Of Condoms Found In Swaziland Sewage Plant.

Three article summaries, as promised

HIV prevalence in India in 2005 (image from article #2 below)

Here are the article summaries I promised a few days back. (Citations and links in pre-Easter entry.) For those more interested in pulpy personal depictions over numbing number-laden journal jargon, scroll down and have a peek at previous posts. -Ry

Article #1:
"Increasing Antiviral Drug Access for Children with HIV Infection
Committee on Pediatric AIDS, Section on International Child Health"

Background: Aproximately 540,000 under fifteen year-olds were infected wth HIV in 2006. A total of 2 million infected kids live in SS Africa, and ~660,000 needed ARVs immediately according to a study done in 2005. [Comment: so much for “immediately”.] Without treatment, about a third die by one year of age and half by two years of age.

Barriers: Though there has been progress in preventing and treating pediatric HIV in resource-rich countries, scaling up in resource-limited areas remains wrought with challenges, including:
· lack of appropriate testing technology for diagnosis, especially in young infants
· lack of health care worker training in pediatric HIV prevention, care and treatment
· lack of availability of ARV formulations that are easy to use and inexpensive (read: cheap pills in smaller sizes needed to replace liquid meds)

The article goes on to make sixteen policy recommendations as to how to address these “lacks”. I can send them to you if you’d like.

[Comment: Examples of our ongoing responses to these challenges are as follows: dried blood spot PCR for early infant diagnosis, HCW training programs (like the one cited below in “quote 7 of 10”), and transitioning to pill-cutting instead of liquid formulation.]

Article #2:
"HIV in India-A complex epidemic"
India has a population of 1.1 billion, a sixth of the world’s population. About one of every eight HIV infected people live there. There are 5.7 million HIV-infected in India, by some estimates more than in SS Africa. While the prevalence is much lower in India (~1% among 15-39yos) compared to Africa (mean = ~20%), the “sheer numbers” serve as a wake-up call. Though the economy is modernizing, India’s slums and vast rural population (70% of total) are home to underweight children (>half of under three year-olds), illiterate women (~50% nationwide), and many other realities that invite the virus to spread—gender inequality (only half of wives report that they “usually participate in household decisions”), spousal violence (37.2% of married women report it), commercial sex work (up to 2 million workers nationwide), and “bridge populations” (i.e. truckers and migrant workers). India, while “populous and complex,” has “substantial resources” and a “record of accomplishment” in addressing other epidemics, and a multifaceted approach to HIV is both possible and imperitive.

[Note: Pardon the brevity and crudeness of this summary; please see complete article for more.]

Article #3:
“Mother-to-child transmission of HIV-1 during exclusive breastfeeding on the first 6 months of life: an intervention cohort study.”

[Note: This one sounds technical but it’s bottom line is important. Many young babies, regardless of HIV status, die of malnutrition in SS Africa. Do read on.]

Background: Exclusive BF, though good for child survival, is rare. This study examines HIV-1 transmission and survival associated with various infant feeding practices.

Methods: 2722 women (HIV+ and neg) were followed while feeding infants, HIV testing was done periodically, and transmission risks were calculated at 6 weeks and 22 weeks of age.

Findings and interpretation, in brief: Mortality in exclusively breastfed infants (median BF 159 days) was lower than those given replacement feeds (6.1 vs 15.1%), and infants receiving solid foods or formula while breastfeeding were significantly more likely to acquire HIV. Infant feeding guidelines need to be adjusted to better support exclusive breastfeeding in HIV positive women with exposed infants.

Why I love my job - Quote 7 of 10

“We are trying to have a sharing of experience.”

This quote came from a speaker phone sitting on the desk of our clinic’s executive director, Busi. We were having a conference call to discuss a new training collaboration between Baylor International Pediatric AIDS Initiative, Swaziland and Elisabeth Glaser Pediatric AIDS Foundation, Mozambique.

D.C., Houston, Mozambique, and Swaziland representatives of BIPAI and EGPAF were on the line.

I haven’t met the owner of the quoted voice (from the EGPAF Maputo office, I believe), but he spoke with authority and a French accent. From what I can gather, is quite excited about the undertaking, as am I.

The plan is to bring eight Mozambican physicians to our clinic (over 3-4 months) and introduce them to our pediatric HIV care and treatment program, while also learning about the challenges that they face in Mozambique.

For me, it is an opportunity to speak Portuguese, share the Baylor experience, and learn what it is like to do similar work in Mozambique.

The first visiting docs are scheduled to come in July.

Plenty of bloggable material will come of this, I am sure.

By the way, we saw 166 patients in clinic today, nine shy of yesterday’s all-time record. I need to go eat something, but will try to post a few more substantial entries soon.

Why I love my job - Quote 6 of 10

“One hundred and seventy five.”

Sibongile said this as she looked at today's patient roster. It is a new clinic record for most patients seen in a single day.

While 175 is a small number in the grand scheme of this epidemic, it is a number that certainly keeps a pediatric HIV clinic bustling.

The more, the merrier, I say...or perhaps, the more, the healthier.

In any case, it is seven thirty, and I still have to do my taxes. I will try to post more tomorrow.

The reason for the season (hint: not the bunny)

Yesterday evening, I was online reading about the origins of Easter, the Easter bunny, the Easter egg, the Easter egg hunt, the Easter basket, and so on. (Like most holidays, Easter’s history is complicated and comprises various traditions, both Christian, 'pagan,' and other.)

As I was trying to make sense of the god "Ishtar" (promounced "Easter" by some) and her relationship to hares and fertility and what-not, my phone rang. It was Grandmommy and Granddaddy (my mother's parents) calling from Ft. Worth, Texas.

We spoke of my work, my next visit to Texas (likely over 6 months away), Sam and Katy’s baby shower, and many other things.

Though it never seems enough when talking through a phone from the other side of the equator and Atlantic Ocean, I told them again how grateful I am for all they have given me, how much I love an miss them.

After saying goodbye, I closed the internet browser because, let’s face it, Easter in essence has nothing to do with Ishtar, hollow chocolate bunnies, colored vinegar, and a tangled nest of plastic grass-like stuff.

Easter is a celebration of the perpetuity of life, the sovereignty of love and renewal in an often spiteful, withering world.

...more or less, I would say, that is what Easter is.

For me, this is a time to be glad that I have beautiful grandparents (you too, Grandma), and to miss them, for the life I cherish comes from them, and they have nurtured me through many Good Fridays and Passovers.

They have also fed me several hundred pastel Hershey’s Kisses and M&Ms over the years.

As you know, I do not use this blog for solicitations, with one exception: Young Heroes. This organization provides relief to Swaziland’s orphans, and does it with next to no administrative costs. Brendan Hayes, a friend of mine and a Young Heroes volunteer, sent me the following image yesterday.

I know that Easter is not nicknamed “the season for giving” and that it does not line up well with the end of the tax year, but no holiday is better suited to defend the sanctity of life, especially life that is vulnerable.

Thank you for reading. Please have a look below.

Link to YOUNG HEROES

Why I love my job - Quote 5 of 10

"[BIPAI's] become a model for the global pediatric AIDS community. This is a model that works."

Quote by Texas Children's Hospital President and CEO Mark A. Wallace, printed in an article in the Houston Chronicle describing the growing partnership between Texas Children's Hospital and the Baylor International Pediatric AIDS Initiative, worth up to USD$10 million.

The funds "will allow BIPAI to open at least 20 new African clinics and intensify its focus on preventing mother-to-child transmission of the AIDS virus."

Happy Easter from Swaziland, with love, y'all

Ostrich Easter eggs (www.animalorphanagekenya.org)

Happy hunting, hopping, jelly bean-eating, decorating and pastel-colored-hat-wearing, in no particular order.

Yours, Ryan

Weekend reading for you - Recent media

In the recently posted minutes from last week's child survival forum, I made reference to "high impact child survival interventions." If you are interested in child survival (i.e. keeping as many of the young ones alive as possible), I recommend the Lancet series on child survival. It offers a wonderful summary of the problem, the challenges in solving it, and potential "high impact" solutions.

In case you would like additional reading for your holiday weekend, I can recommend three more important articles. They are more recent and specifically relate to HIV.

(1) The American Academy of Pediatrics recently released an important policy statement titled "Increasing Antiretroviral Drug Access for Children with HIV Infection."

(2) The New England Journal of Medicine's March issues (March 15, 2007 and March 22, 2007, I believe) contained several articles discussing the HIV epidemic in India.

(3) For those interested in recent [more technical] news on infant feeding in the context of HIV-infected mothers, the recent article by Hoosen Coovadia is a necessary read. It is titled "Mother-to-child transmission of HIV-1 during exclusive breatfeeding in the first 6 months of life: an intervention cohort study."

I do not have time to summarize these three articles right now but will do so soon for those of you who cannot access the full text with the links provided, and for those others among you who prefer thier news spoon-fed, partially digested, etc.

Why I love my job – Quote 4 of 10

“Lomtfwana ubukeka amuhle.”

She looked me straight in the eye as the said this, and chuckled as the SiSwati words rushed from her mouth. Her face was creased as smiling faces sometimes crease when skin bunches around the nose, eyes and forehead. Her words were dripping with gladness. Her handshake whitened my knuckles.

“What did she say?” I asked my translator, Thembi, after the old lady left the room.

“She said that she is happy. The gogo is very happy that the child is looking good now.”

The child is a 6 year-old named Phumile, and she started ARVs two years ago. Her previous health dossier included herpes zoster, chronic upper respiratory tract infections, pulmonary TB, pruritic papular eruption, and other things that nobody wants on his or her health dossier.

Translated directly, the quote means "the child is looking good now."

Indeed, she was.

(I sometimes find it hard to believe that I actually get paid to watch sick children look better and better.)

What am I up to (March-early April, 2007)

Swazi landscape as winter approaches. (www.sntc.org.sz)

It is autumn here, though there are few deciduous trees to make it feel like “fall”. Still, the air is crispier these days. The limp, heavy days of the summer months (December, January, February) are moving northward, accompanied by the rare, disoriented African migratory bird.

Of late, the air no longer presses down, demanding submission and stillness. Sweat no longer glues shirt to flesh, leaving one uncomfortably closed in.

Swaziland’s many claustrophobic, poorly ventilated rooms breathe at long last.

The breeze, while cooling stuffy, damp corners, brings with it a certain restlessness, perhaps a beckoning to prepare for the never-frozen-but-brisk, short winter days ahead.

The drought of this past summer (usually the rainy season), guarantees that many winter days will restless indeed. There will be many hungry, thin days here soon. Life-threatening days.

Today does not seem one of those days. It is an auspicious day, a playful day, a reminder that the world is often short on but not devoid of merriment. The waiting room teems with hope and youth.

I spent the day seeing patients. I had the pleasure of telling two mothers that their babies were HIV negative (by DNA PCR). I had the [distinctly different] pleasure of telling another mom that her severely malnourished 6 year-old had a good chance of some day being strong and plump, of some day regaining enough strength to walk, even run. She had lost hope that this was the case, and simply said, “Ngiyabonga.”

I am still uncomfortable when people tell me “thank you” when I am simply doing my job.

Last week, I attended a meeting on child survival, hosted by UNICEF and designed to bring together all Swazi NGOs that work to protect the health of less-than-five year-olds. See next entry for some excerpts from the minutes. They are not exactly light reading, so feel free to skip over 'em.

Tomorrow, I am working on our clinic’s monthly report, which I hope will summarize our progress over the month of March. Even in name, “March” seems to imply advancement, and advanced we have. (I need grammer check for that one.)

In any case, I will share some excerpts from the report too, once it is complete.

Beyond pediatric HIV, I plan to learn a few guitar cords soon. (I was recently told that well-rounded men play some musical instrument.)

I have been rushing to squeeze as much swimming, biking and running from the shortening days as possible. Not much summer-juice left, and these activities are becoming darker and cooler every day. I am actually in the market for a runner’s headlamp and wetsuit. Any leads?

I have plans to travel to south-central Mozambique at the end of the month, but will otherwise be around the kingdom. Do drop by if you please.

Seleted meeting minutes - NGO workshop on child survival in Swaziland, March 28-29

Presentation #1: “Countdown to 2015: Causes, trends and high impact interventions for reducing child mortality in Swaziland” (Dr. Sid Nuripam of UNICEF/MOHSW)
Preface: Child survival by necessity focuses on <5yo as most deaths in this period
Facts on global child survival
o >10 million die from preventable causes in developing world annually
o Millennium Developmnet Goals 4 (MDG4) designed to cut this number
o 60 priority countries (Swaziland included) account for 94% of these child deaths.
Swaziland situation
o <5 mortality in 1990 = 110
o MDG 4 = 37 by 2015
o <5 mortality in 2005 = 156
o Average ‘reduction rate’ = -2.5% (note negative sign)
o Much of this trend is HIV-related
Pie chart presented reflecting causes of death in Swaziland: 47% HIV/AIDS, 27% neonatal (tetanus, infection, asphyxia, etc.), 12% pneumonia, 10% diarrhea, 4% other (malaria, etc.) = 100% total.
There are simple interventions for these preventable/treatable diseases.
Note: Malnutrition not included on the causes of death list because not immediate cause of death, but contributes to >50% of child deaths.

Presentation #2: “Findings of study on NGOs currently supporting high impact Child Survival interventions” ( Ms. Mavis Nxumano , Child Survival Focal Person, MOHSW)
Summary:
§ Strength: 26 NGOs supporting 2+ interventions, half receiving govt support
§ Weakness: NGOs poorly coordinated by MOHSW; poor knowledge of high impact interventions among NGOs
§ Opportunity: NGOs willing to coordinate; “Child Survival Coordinator” identified by MOHSW
§ Threats: Weak leadership at MOHSW; lack of coordination

Discussion excerpts:
· “Government should play a leading role…Please, be seen playing a leading role!”
· “As government, including myself, we are not doing much to put things into place.” “We are the ones who are letting it get away.” “We are missing an opportunity of a lifetime which we may not have ten years down the line.” “If we fold our arms and not bother [the politicians] we will be sorry.” “It’s an embarrassment.” “We are waiting for government for ABC. Who is government? We are government!”
· “I am so pleased to have this kind of meeting. We [government and NGOs] are increasingly working hand in hand…Over the last 3 years, there has developed a sense of cooperation.”
· We need [governmental leadership], “Not the cosmetics of having workshops in expensive hotels.”

Why I love my job - Quote 3 of 10

“La la…la la..…la la la la…….la la.”

This quotation is attributable to an 18 month-old patient, named Khayalethu, on her way down the COE hallway to my exam room today.

She was started on treatment for extrapulmonary TB in February, 2006, initiated on ARVs in June, 2006, and singing on this 3rd day of April, 2007.

She sings for good reason…her TB is cured and her CD4 count has nearly tripled.

To hop and chase - A [nonclinical] patient encounter

www.sos-childrensvillages.org

I walked sneakily around the playing children, afraid I would interrupt their game.

I was on my way to the car to grab my usual breakfast—two packets of Jungle Oats instant oatmeal. (“Apple-Cinnamon”, “Tropical Fruit”, and “Caramel” are my favorite flavors, in that order; I do miss Quaker Oats' “Cinnamon & Spice” and “Maple Brown Sugar” flavors, though. No maple trees here in Swaziland. Few Quakers.)

As I walked back from my car toward the clinic’s entrance, all five of the kids were hopping around on one foot, following one another around a small imaginary circle. A few of them were themselves spinning as they hopped.

A small solar system of giggling pediatric HIV patients.

I casually backed up and leaned against the glass window beside the clinic entrance, watching the twirling. Spontaneously, the circular, spirited hopping became a game of circular chase, with the ~7 year-old chasing the ~5 year-old chasing the ~4 year-old chasing the two ~3 year-olds. The older children were running just slow enough to make the race sporty.

I used to offer the same advantage to my brother, Nick, when he was young. He is now bigger, stronger, and faster than me and regularly returns the favor.

After a full minute of orbital chasing, the oldest child suddenly broke away to see what a nearby ~2 year-old (his sibling, I think) was eating. Whatever it was, it appeared to be from the ground, and the ~7 year-old dutifully took the morsel away and discarded it in the direction of some nearby bushes.

He then picked up the small child in that way that small children pick up slightly smaller children, with a slight bend of the knees, and upwards heave, and a carefully-timed sideways thrust of the hip, after which the slightly smaller child lands with an thud and soft grunt while grasping on to whatever the other child is wearing, or, if reach allows, the neck.

The two wobbled a bit and then moved toward the clinic door.

I turned in the direction of the entrace as well and waved to the remaining children, who were still running in loops. As I turned to follow the wobbly pair, the four kids suddenly ceased giving chase to one another and, like an uncoiling spring, charged towards me.

They formed a small semicircle (trapezoid?) around me, which gave me a brief start, then, with much youthful pomp, they waved back.

I waved for a bit longer, then, feeling the need to do something different, gave a thumbs up. The four answered with the same before elatedly running back to their patch of grass to continue to find simple pleasure in simple games that I long ago abandoned to become a grown-up.

Now I just watch and try to remember enough of the experience to write it down so that you might see a bit in my words how these children do not deserve to die of a treatable disease, so that you might catch a brief, up-close glimpse of just how arbitrarily nature allocates its afflictions.

Why I love my job - Quote 2 of 10

“I have noticed that maybe there is an effect on growth. He is growing faster since the medicines. He plays football with the others, plays moto, runs, does everything. Everything with the others.”

I asked the grandmother what she meant by “moto”, and she explained that “moto” is a type of contest where the children build cars out of wire and see which one is the fastest, biggest, fanciest, and so on.

I have seen these cars. There are many varieties, but they have one commonality: they are toys made from common materials, often scrap metal and leftover jugs, bottles, tubes, etc.

I once saw one equipped with battery-powered FM radio. (I think I have a photo of it somewhere.)

Until I unbury it, I offer the following examples from the internet:

www.junglephotos.com

www.synesthete.com

www.askadavid.org