Thursday, May 31, 2007

Aspiring to reach blasé – Introducing Mncedisi (9 of 10)


The look that Mncedisi is giving the camera is the same look he fixed on me for the duration of our clinic visit.

It is a facial expression that I have only rarely seen worn by an adult.

Time teaches old folks not to stare. We learn to hide our curiosity and dilute our public displays of wonder.

The word "wow", a daily expression for the newbies as they experience the world anew, rarely survives adolescence.

This is one of the reasons I enjoy the pediatric patient population. (Vicarious youth is better than none at all, no?)

Well, Mncedisi's raw stare of curious wonderment was as interminable as it was unapologetic.

Though this was a typical day for this Swaziland-based pediatrician, this was not a typical day for Mncedisi, and he didn't want to miss anything.

As you can see, he didn't miss much.

He studied everything. He watched my stethoscope move toward his chest and stop there. He looked at me, then the bell of the device, me, then the tube of the device, me, then his mom, me, then back to the bell, and so on.

Then his hands got involved. He touched each part of the stethoscope, with alternating looks at me and mom. (The right hand he has casually resting on his jacket in the photo went immediately for the camera when it was within reach.)

We don't know if Mncedisi is HIV positive yet. His DNA PCR is still being processed by a lab in South Africa.

Regardless of his status, he will have the opportunity to grow up and see many new things. He will even grow old enough that those new things begin to seem routine.

Wouldn't it be great if every child were able to be around long enough to know what it felt like to be bored, unimpressed?

Wow. Now that would be something.


Wednesday, May 30, 2007

I really do love this work - Introducing Gugu (8 of 10)


Gugu has a story similar to many of the other kids we see. She is HIV+ and, without treatment, has a 50-50 chance of not surviving 2 years.

While all kids are adorable, Gugu is incredibly so.

I really do love this work.


Monday, May 28, 2007

Memorial Day, 2007

A thank you to the men and women who died in military service to foster and protect the place where I was born.

I am fortunate to hold a passport that grants me the privilege of living and working abroad.

I am proud to be from a country that allows, even encourages, its citizens to do so.

I am reminded of a particular quote from JFK, originally from Luke 12:48.

"Of those to whom much is given, much is required."


I pass a particular graveyard several times a week here in Swaziland. It looks nothing like the one above. It has clumsy stacks of brown rocks marking the crowded graves, and the plot is awkwardly placed on a hillside with little vegetation, so that the loose red dirt, when it rains, runs downhill toward the primary school in the valley.

It is a earth-toned place. There is no green there. No flags.

I watched from a distance as they unceremoniously buried a young man there a few months back.

One hundred and one Swaziland destinations- #7: Esibayeni Lodge and Conference Center

For those who follow this blog and know of my recent my car-cow crash, consider the following subtitle for this post: "Revenge of the bovines."

Esibayeni banner and conference room. (Ours actually had elephants on the wall.)

As suggested by the photo, Esibayeni is a superb place to have a conference. The training there last week (see below) went swimmingly. Many Swazis choose this lodge for weddings, parties, etc, and for good reason.
Among Esibayeni's many claims to local fame is it's beef tripe.
It has been said that it should not be missed.
Well, when this was said to me, I looked down into the steaming metal pot housing the stuff and trustingly heaped some of the moist, rugae-laden morsels atop my rice.

As I did so, a fellow eater whispered to me, "A true delicacy."

The contents of the steaming pot, some of which was now on my plate, looked more or less like the tripe depicted in the photo above, but more gray in color, with thicker sauce....and thicker rugae.
In any case, I did try it.

"How did it taste?" you ask?

My answer: "like beef bowel."

Do not misunderstand. I am not saying not to try tripe.
Tripe, while a trifle trying for this trier, is worth a trial try.
All Swazi food is worth a go, for that matter, for it is [almost] all quite excellent.
All I am saying is this: certain delicacies needs to be sampled delicately.


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

Baylor Swaziland is funded by UNICEF to organize and complete periodic regional trainings. The first training of this fiscal quarter was last week. The teachers were a handful of Baylor staff and myself. The pupils were twenty community nurses. Here is an overview.

MONDAY: Lectures included: epidemiology of HIV in Swaziland, the pathophysiology of HIV, the diagnosis of HIV, and primary care of the HIV+ child. Highlights included:
- The opening song; though we started about three hours late, the group immediately distinguished themselves as a pitch-perfect choral ensemble, despite the fact that it was the first time they had ever been in the same room, much less harmonized.
- The five minute video of the HIV lifecycle: It is an animated production that makes HIV look like a spherical spaceship and uses sci-fi images to teach how HIV multiplies. Imagine what Steven Spielberg would see if he looked into an electronic microscope.

TUESDAY: Lectures included: ARVs, TB, opportunistic infections, and PMTCT. Highlights included:
- The OI case identification contest. For the opportunistic infection lecture, I presented a series of cases. The participants, who were divided into teams, were tasked with identifying the OI in a format similar to final jeopardy. In the end, a team who had named themselves “the ducks” narrowly defeated “Wonderboy’s team”. Other team names included “the women of excellence”, “the Zambians”, “the elephants” and the ever-popular, internationally renowned “A team”.

WEDNESDAY: Lectures included: ARVs, TB, opportunistic infections, nutritional management, and infant feeding. The repeats are due to the scheduled rotation of half of the group though the Baylor Clinic on both Tuesday and Wednesday mornings. Highlights included:
- The infant feeding workshop, ran by Eileen, which allowed the attendees to rotate through stations and perform various tasks, including growth charting, dietary advising, lactation counseling, etc.
- The shining feedback from the half-day clinic visits. Comments included:
o “It was very very touching to me. When the mother entered you could see depression and all of the things she was going through. The explanation she got [at the clinic,] the advice, it was good.”
o "That the pharmacists sit down with everybody and not that song that we usually hear. At times, when you see the queue you just say two times a day of this, two of that. It is not the best way. At Baylor, the way they counsel and label the medicine, it is good.”
o “Every thing was in order.”
o “I liked the way they kept records, on…what do you call that thing?” Another nurse replies, “Computer?” “Yes! The computer! We should use them too.”

THURSDAY: Lectures: counseling about HIV, adherence to ARVs. Highlights:
- Nosipho, the social worker who gave these lectures, told a story about a HIV+ man who, not knowing his status, entered a Swazi testing center with a gun, put it down on the table in the counselor’s office, stood blocking the door, and said “Okay, I would like my results now.” “What would you do?” she then asked the group. A lively discussion followed. Answers included:
o “Tell him he is negative.”
o “Tell the truth.”
o “Ask him to please come back later.”
o “Quickly grab the gun.”

FRIDAY: Lectures: Case presentations by participants illustrating what they learned. Highlights:
- Having promised to lead the morning song if the group maintained punctuality, I delivered on that promise. In an attempt to cover for me, the chorus of nurses sang backup even more beautifully than they had in days prior.
- The discussion about the “way forward” after the workshop was heartening, with participants expressing a desire to return to their respective clinics and institute several new practices, including:
o Improving adherence numbers and follow-up
o “Need to probe more regarding HIV status”
o Renewed focus on PMTCT
o Improving the physical exam for recognizing HIV cases
o To start ARVs early, before the child is too sick
o More diagnostic attention to improve and guide care
o Improving HIV staging
o When a patient is on ARVs, to “recognize the drugs, review them, and advise.”
o To share ideas and lessons learned with other colleagues after returning from the workshop.


Last week was a good week. Except for the tripe, that is. (More on this soon.)

This week, I am back to seeing patients. (More on this soon as well.)


Sunday, May 27, 2007

Recent media – Diminishing workforces and community workhorses

See the links below for the latest on African workforce challenges and community-based HIV advocacy efforts.

MSF warns on southern African AIDS programmes (Thanks for sending me your article, Fran.)

HIV/AIDS and Local Action – The Drum Beat


Friday, May 25, 2007

One hundred and one Swaziland destinations- #6: Mlilwane Wildlife Reserve

Mlilwane and a big bird.

More Mlilwane residents.

This is where I am going biking tomorrow morning. If the hippos stay on the island, I should be fine.

Enjoy the weekend. More blogging soon...


Thursday, May 24, 2007

If a child is sick...

Kizza, age 6.

Paul, age 17.

Stella, age 13.
I watched the documentary “Living with Slim” again this morning. We played it for the twenty hearth care workers (primarily nurses) that are attending this week’s UNICEF-sponsored five day pediatric HIV training course. (It is the first of six such trainings this year in Swaziland.)

I plan to write about the highlights of the training soon. There were many. For now, I wanted to share with you a few of the quotes from the short documentary. I have emailed the filmmaker requesting copies and the film's transcript.
Here is the excerpt:

Moderator: “What do you want the world to know about HIV?”
Kizza: "That is hurts."

Paul: “It’s a very bad disease if it gets you. It treats you badly. You are not comfortable.”

Stella: “That if a child is sick you must not treat them badly. You must treat them well. As though they were your own.”

Recent Media - "Who shot JR?"...and other news

The Dallas Morning News has recently generated some good BIPAI-related readin' for any interested. It is not about JR. That was meant to peak your interest.

"Texas doctors helping African kids with AIDS"

"African health care crisis dwarfs relief efforts"



Wednesday, May 23, 2007

Moo - Part 3

Continued from Parts 1 and 2 below.

“Nope. It can’t drive,” I said.

Nor could I, it seemed.

I thought back on what I might have done differently. As I had approached the sharp curve, there actually had been a man wildly waving his hands at me. I thought that he was an overzealous hitchhiker (happens a lot) until I saw a truck with flashing blue lights pull onto the road and begin following me. Thinking I was being pulled over (happens a lot), I began slowing down as I approached the curve…and then came the thud, my bad word, and the rush of that feeling which I will call the “darn-it-all-oh-no-did-that really-just-happen” feeling and the adrenaline that couples this specific, unpleasant feeling.


“Do you know any tow trucks that can pull me to the border?” I asked the officer.

I did not intend to loiter at the scene of the “auto vs. cow” altercation. I wanted to do nothing but leave, actually, and soon.

Well, that is not true. I wanted to put a bullet in the skull of that poor cow carcass in case it had survived the three collisions, but needless to say I didn’t have a gun. The cops (now there were three; one for each thud) all had guns, each discreetly tucked into his/her pants, but they did not want to use them.

“The owner of the cow must come so we can issue a citation,” one of them said.

In any case, I was ready to move on. I was uneasy and hungry and wanted a tow to some place that had electricity and a veggie burger.

“Can I see that torch hat again?” asked the policeman. “We found a brand on the cow and I want to use it to identify the owner.”

“Here you go,” I said.

I made a few cell phone calls to folks in Swaz and cashed in a few favors. Each of the conversations started with me saying, “Listen, I have a bit of a problem.”

After ten minutes of favor-seeking, there was a Swazi tow truck (with my name on it) on its way to the Swazi-South Africa border. I just needed to get myself and my disabled station wagon to the South African side of that same border.

I hung up the phone and looked for the light from my headlamp. Its white 3-LED light was ten meters behind the car and focused squarely on the fated cow’s rump-steak. A semi-circle of semi-illuminated observers had gathered. The cow’s brand symbol was being copied into the officer’s notebook.

I approached the lamp, the lighted cow, and the dozen or so half-lit bystanders and asked the cop, “Any word on that tow truck?”

“Oh…Hmmm…Do you have any minutes on your phone?”

“I sure do.”

Fortunately, I had put ten bucks on my Nokia in Carolina, a small town I passed through about an hour before.

He dialed a number on my phone, spoke for a while in Zulu, hung up, and told me that a friend of his was on the way.

I thanked him, hoping he was on his way in a tow truck.

Then the police officer then said, “We really need to go.”

I paused to digest and reflect upon what had just been said.

“Um, please don’t do that,” I retorted.

“I have a robbery suspect in the car, and I am now off duty.”

“Um, please don’t do that,” I re-retorted.

“I can’t stay.”


I thought about offering to pay him but instead avidly volunteered to write a letter to his boss describing how he—Officer Buthelezi—generously did not leave me on the side on the road in rural South Africa on a dark dark night.

“I am going to grab a pen and paper to get your name and the station address!” I said, running over to my lame car before he could object.

I took his information and the name and phone number of the department head.

The officer then generously waited the fifteen minutes until the truck arrived.

After one South African pasture-to-South African border tow truck, two nuanced border debates (one in each country regarding the export-import of damaged cars), and one Swaziland border-to-Swaziland mechanic tow truck, I was back at home, more than a little bit relieved.

I am not sure what happened to the victimized cow.

As regrettable as the whole affair was, given the circumstances, I am thankful that the animal was the only casualty.

Moo - Part 2

Be sure and read Part 1 below if you have not...


The first thing I did was say a bad word. Just one.

I make this confession without remorse, because not only did I have no control over the escaping expletive but it was an accurate expression of how I was feeling at that fateful instant.

A few seconds later I had regained all faculties and, this being the case, I frantically started searching for flash lights. I had three in my back seat, and they were desperately needed.

When a dead black cow is in the middle of a curvy, unlined, black road on a black, moonless night, flashlights come in handy.

Two cars had hit the animal before me (both cars totaled) and there were three near misses before I found the lights.

I handed one to the police officer, who had just arrived on the scene in response to the first collision.

“This is a nice torch!” he said, walking out into the road and waving off oncoming traffic with my favorite headlamp.

“Thank you,” I said, not really meaning it. I wanted to go home, and I was not going home any time soon.

After a few minutes of waving my three lights at approaching cars, there was a large enough crowd to drag the mega-cow from the road.

With the large, lifeless hazard in a less hazardous spot, I had time to point the light at my car.

The police officer, my Petzl headlamp in hand, came up behind me.

“Did you hit it?”

I inspected the broken right headlight, the horn-shaped dent in the hood, the horned-colored scrape inside the horn-shaped dent, and I said, “Yep, I did.”

“Can it drive?”

I inspected the right front tire, which looked fine. I moved over to the left one, and it looked fine as well. However, according to the right tire, the car was turning sharply to the right. According to the left, the car was poised to hang a left. I stood up, walked over to the steering wheel, and with additional disappointment noted that its intended direction was straight ahead.

“Nope. It can’t drive.”

To be continued...

Monday, May 21, 2007

Moo - Part 1

Driving through the South African countryside is similar to driving across central Texas.

Bucolic rolling hills, farms, pastures, cows, and big big skies.

Very few fences, though.

Many cows, few fences.

Last night, in the fading twilight, as I drove around a dark corner, the high cow-to-fence ratio of this part of the world became immediately and abundantly clear.

The sun had just set over the distant horizon. The beautiful shroud of colors reminded me of the sun going down at home.

Daylight had plunged far into the earth. My rearview mirror was deep purple, roughly the color of venous blood. All ahead was bile-black.

Pitch, charcoal black.

The moon was either new or had fallen from the sky, for moonlight there was none.

As I rounded the bend, a form in my headlights took shape. Even the shape was midnight black. Big and midnight black.

Oil black.

The whole sudden affair had no precedent, at least not in the life of Ryan Phelps. Well, actually, the shape was not unprecedented. I knew exactly what it was shaping up to be. The unprecedented part was the speed at which the shape-taking took place.

While I was traveling well beneath the speed limit, the obstacle spryly leapt from the soupy darkness as if I were breaking the nighttime land speed record.

It was only in retrospect, as I stood beneath the new moon, that I realized that I had been warned.


I was returning from Pretoria after a long weekend of camping, eating, and sightseeing. Highlights of sights seen included a big white rhinoceros and baby lions. While the rhino was wild, the cubs were not (see photo below).

Ryan and lion.

A wild rhino is an impressive sight. It is like an armored car, except it grazes and has legs.

Many would argue that the lion cubs pictured do not belong in captivity. I tend to agree, and actually feel that they also do not belong in my arms. There are two reasons for this. Claws and teeth. Actually, I counted eight claws and two particularly long teeth per cat.

Eight plus two is ten reasons…so at least ten reasons not to carry lions around, even cute little ones.

Well, some lessons come later in life than they should.


I am from Texas.

The first time I saw rhinos and lions, it was at the Ft. Worth Texas Zoo. I did not know at the time that the animals were of African origin, but eventually I figured out (with age) that not all big and impressive animals were native Texans.

While the continent of Africa did not make it into my primary and secondary public school curriculum, Texas definitely did.

I had two years of Texas history at ten years of age. World history was a one-year course seven years later..

Texas, I learned as a preteen, is historically oil and cattle country. We took the oil out of the ground and put it in barrels and we took the large cattle herds of the central plains, herded them, and put ‘em in corrals.

Yee haw.

Swaziland has little “Texas tea” (a.k.a. black gold, oil, etc.), but it is, like my home state, very much cattle country. While the history of Swaziland was not covered at Denison, TX’s B. McDaniel Middle School, I have been here for the better part of a year and I can tell you with confidence that cattle play heavily into daily life.

While Texas cow culture is now for the most part a thing of museums and while roping and riding is now largely for rodeo performances, raising cattle here remains an essential, life-preserving vocation for Swazis. There are still cowboys in Texas, of course, and the steakhouses are hard to beat, but here in Swaziland bovine ownership represents financial and nutritional security. In many rural areas, wealth is still measured in cows.

Cows, after all, provide milk and meat and usually retain their value.


(To be continued…)

Saturday, May 19, 2007

Yesterday was HIV Vaccine Awareness Day

Yesterday marked the 10th annual HIV Vaccine Awareness Day, an opportunity to reflect upon the more than two decades of progress worldwide in the search for a safe and effective HIV vaccine.

The urgency of finding a safe and effective HIV vaccine is underscored by sobering statistics, familiar to those who regularly read this blog: Forty million people are currently living with HIV infection. Every day, another 11,000 individuals become infected with HIV, most of whom live in resource-poor countries. Last year alone, it is estimated that more than 40,000 individuals in the United States were infected with HIV.

In the coming years, several major trials testing different vaccine candidates and approaches will be completed. Results of two ongoing efficacy trials — a large-scale 16,000-person trial in Thailand and a smaller 3,000-person trial in North America, South America, the Caribbean and Australia — are expected in the next two years. Results of another 3,000-person trial in South Africa will follow. Although none of these trials is expected to lead immediately to a licensed vaccine, each study adds to the body of knowledge that helps shape future vaccine efforts.

(Adapted from the HIV Vaccine Awareness Day statement from the National Institutes of Health )

Thursday, May 17, 2007

Brilliant and wide - Introducing Nontokoza and Bongani (7 of 10)

Nontokoza and her mother

Bongani and his mother

There are few smiles as brilliant and wide as the smile of a mother when she learns that the medicines she took during pregnancy prevented her child from becoming HIV infected.

Though the custom here is to not smile too much in photos, I can assure you that the joyful faces of these mothers when I told them of their child's status would have moistened your eyes.

Mine glisten every time.


The prevention of maternal to child transmission of HIV is a topic I have discussed extensively in this blog. There is way too little of it. Scroll down if interested in learning more.


Tuesday, May 15, 2007

Delightfully routine - Introducing Siphesihle and Mduduzi...and Mom (6 of 10)

Mduduzi, Mom, and Siphesihle

I know that I looked strange by the way Mduduzi looked at me. It is almost certainly due in part to the color of my skin, for I am sure that he has interacted with only a handful of white people before, much less been trapped in a small room with one.

I reckon that I look and sound very unfamiliar to Mduduzi, for he gazed at me with intense uneasiness and fascination. He would look away only to make sure that his sister and mother were nearby to protect him.

When his older sister, Siphesihle, looked at me, she apparently found no novelty or cause for concern. She had outgrown any fear or intrigue that I might have once inspired.

This was just as well.

To be honest, I felt the same as she did.

Mduduzi and Siphesihle were just two more kids that had been very very sick until we put them on ARVs, and, like the rest, they are now thriving.

When I saw this turnaround for the first time, I was fascinated by the seemingly miraculous transition.

It was new...and awesome.

Now, I have seen so many Mduduzi’s and Siphesihle’s that I almost find them routine.

Blessedly, delightfully routine!

Awesomely, miraculously routine!

…at least at the Baylor Clinic.

The norm elsewhere is unlikely to delight.

I gave Mduduzi one more reassuring smile, thanked his mom for seeing that the children get all of their meds, and opened the door so that he could return to familiar surroundings.

I sent his ARVs with him.


Recent Media - HIV/AIDS out East

A more interesting title for this blog entry would be, "Drugs, Sex, and Oriental Soap Operas".

While this site is focused primarily on Swaziland (esp. HIV in Swaziland), I do sometimes venture elsewhere. I have recently written posts on India, Mozambique, for example.

As a kick-off to my latest world tour of HIV news stories, I have reviewed May’s leading “HIV in Asia” headlines and put together the following list of articles, each with a very short summary.

(I especially like the penultimate one, and the pre-penultimate NEJM article on China is also a good one to browse.)


Half of Chinese refuse to work with HIV/AIDS carriers: report (May 14)
52 percent of survey respondents said they would not work with an HIV/AIDS carrier, while 49 percent said the same of Hepatitis B carriers. More than 55 percent of the repondents said they would not hire carriers of either disease.

Sex education creates storm in AIDS-stricken India (May 14)
Moves to bring sex out of the closet in largely conservative India have kicked up a morality debate between educators who say sex education will reduce HIV rates and critics who fear it will corrupt young minds.

Asian drug users need more HIV prevention help (May 14)
An editorial arguing that Asian countries need to wake up to the threat of HIV transmission via intravenous drug use and spend more money on needle exchanges and other programs or risk a rapid rise in new cases.

Managing Substance Abuse And HIV In Malaysia (May 14)
In Malaysia, more than 30,000 opiate-dependent patients are currently treated with such medications as naltrexone, buprenorphine, and methadone. Despite the high prevalence of HIV and other infectious diseases among addicted people, few HIV prevention efforts have targeted Malaysian drug abusers, who represent only a minority of patients receiving antiretroviral therapy.

First HIV/AIDS Diagnostic Center Opens In Northern Afghanistan (May 14)
The Center began operations today. A mere 71 HIV cases have been reported in the entire country, but health officials soberly report that the numbe could top 2,000. Refugee populations and a lack of proper testing centers are the primary reasons for the spread of HIV in Afghanistan. The Health Ministry is planning to open testing facilities in bordering provinces to prevent the spread of HIV from Tajikistan, Turkmenistan and Uzbekistan.

More Thais to get AIDS drugs under deal (May 9)
Tens of thousands more Thais will receive desperately needed AIDS medicines under a deal announced by Bill Clinton to slash the cost of cutting-edge drugs. Under the deal with two Indian drugmakers, Thailand will be able to buy advanced anti-retroviral drugs at a fraction of the current cost

10M Children In South Asia Affected By HIV/AIDS, Officials Say (May 11)
While only a small portion of these children are HIV-positive, millions have one or both parents living with the virus or have been orphaned by AIDS. "The time has come to put children at the center of the debate." South Asia comprises Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. One quarter of the world’s children live in these eight countries.

China Must 'Move Quickly' To Control Spread Of HIV Because 'Situation Could Worsen Rapidly,' NEJM Perspective Says (May 8)
China is undergoing rapid social and economic change -- including migration from rural to urban areas and increases in commercial sex work and drug use. "Given China's enormous population, even a small increase in [HIV] prevalence could be devastating." Among new HIV cases in China, 48.6% are caused through injection drug use, 49.8% through sexual contact and 1.6% through mother-to-child transmission. Full NEJM article here.

South Korean Soap Opera Aims To Reduce Discrimination, Stigma Surrounding HIV (May 8)
The television soap opera, called “Thank you” aims to reduce the stigma and discrimination associated with HIV/AIDS by portraying the story of an eight-year-old, HIV-positive girl. It has been receiving top ratings in its time slot, reaching 18.5% of television viewers. A 2005 survey of South Koreans found that 52% would not send their children to school if another student was known to be HIV-positive, and that 40% of respondents thought that HIV-positive people should be quarantined in special facilities. According to United Nations estimates, South Korea’s HIV+ population could be as high as 13,000.

India's DBT And IAVI Forge Partnership To Develop 'Next Generation' Vaccine Candidates (May 3)
The Indian Government and the International AIDS Vaccine Initiative have signed an agreement to partner on HIV/AIDS vaccine research and development. Under this agreement, Indian and U.S. scientists will work to accelerate the discovery of an HIV/AIDS vaccine and develop new concepts for the "next generation" of vaccines.


Sunday, May 13, 2007

Grinning and no longer having to bear it – Introducing Sharon (5 of 10)


Last year, Sharon had a hemoglobin of ~6 (severe anemia), oral thrush, and recurrent lymphadenitis (infected lymph node(s)). When I saw her last week and refilled her antiretrovirals, her ailments were ailing her no more and thus required little of my attention.

So, Sharon's mother and I spent most of the visit talking about how much she likes to smile.

As for Sharon, she spent most of the time smiling.


Happy Mothers’ Day from Swaziland, with love

Me and Granddaddy with our beloved Grandmommy Hatt, my mother's mother. (Denison, Texas, December, 2006, when I was last home).

Grandma Phelps, my father's mother, creates her famous pan-fried polenta. (Bend, Oregon, May, 2005)

Sarah (my sis), Nick (my bro), and Ryan (myself) with our mommy, Jeannine Hatt Phelps, deep-frying somethin' (not polenta) on the Phelps Ranch. (Denison, Texas; June, 2006).

A hug and kiss from the Kingdom of Swaziland, with love, to the three incredible mothers pictured above.

As for the rest of you:

If you are a mother, my heartfelt congratulations and gratitude.

If you are a grandmother, my heartfelt congratulations and gratitude.

If you care for children without mothers, my heartfelt congratulations and gratitude.

If you would like to help care for children without mothers, please read on...


Thank you.

One hundred and one Swaziland destinations- #5: Slick Rock Creek Trail

I named the trail myself.

The name is based on the small river that serves as the half-way mark for the out-and-back ride that we did yesterday morning. Actually, the name was first inspired a few months ago by a deep bruise that resulted from a tumble I took while walking shoeless across the slimy creek bottom.

It's better now.

While we have only biked the route twice, it is already a new favorite. For an illustration of some of the trail’s highlights, see the arrowed photos and captions below.

The start of the trail, about 6km into the ride. The arrow is the approximate location of the creek.

Slick Rock Creek, with my weary bike in the foreground. The arrow represents the general vicinity of the trail's beginning, where the first photo was taken.

The return ascent continues. Note the elaborate Swazi homestead in the foreground. It is one of the few along the route. (Even a few miles outside of Mbabane, the Swazi countryside is sparsely populated...and quite poor.)

The Slick Rock Trail Fan Club: me, Dr. Eric Raabe, and Dr. Eric McCollum.

Bright, pretty flecks – An addendum to "101 Swaziland destinations - #5"

I was worn out from the continuing ascent from the valley, and my body was on the verge of mutiny as my brain’s metronome-like Coxswain stubbornly shouted, "pedal!…pedal!…pedal!"

I was beginning to wonder how much a used mountain bike would sell for in Swaziland.

When I turned the corner, there were about twenty of them. They were flecks of vivid highlighter-yellow and they were strewn about the path in front of me like confetti. Until they took flight, I would have guessed that they were careless litter, perhaps a shattered plastic bottle.

(How butterflies fly at all is a mystery to me. They seem to have too much wing and not enough chassis, as if they were designed to simply be blown about by the wind, like a tiny, poorly outfitted, crewless sailboat…or a dry leaf.)

I came to a stop a few meters from them, and they rose into the air, swarming.

In most cases, I want nothing to do with swarms of anything.

A swarm of fluttering yellow butterflies, it turns out, is remarkably unthreatening.

Against the backdrop of the ongoing drought’s drab, merciless earth tones, the swarm provided a marvelous distraction, a respite for the two large overcooked lasagna noodles that had only recently been my legs.

The pretty bugs gave my brain something to do besides taunt my body.

While the butterflies’ formation was more haphazard than that of, say, migrating geese, there was definitely an intricate order to it. The clustered flight paths reminded me of those tedious informational cartoons we were shown in general chemistry class that were intended to teach us how electrons encircle an atom’s nucleus.

In other words, they swarmed spherically, as if they were frantically rolling an invisible ball of weightless yarn.

I watched them float about until I had caught my breath and then told myself that, if these disproportionate, dusty-winged insects could so effortlessly fill the air in front of me with bits of precisely-woven color, I could force my worn-out legs to pedal a bit further.

So I did, and eventually made it up the seemingly interminable hill.

I must admit that there are times when having wings or a lighter-weight frame would come in handy.

Friday, May 11, 2007

One hundred and one Swaziland destinations - #4: "Rock of Execution".

Nyonyane Mountain, also known as the “Rock of Execution”, is in the middle of the Mlilwane Wildlife Sancuary, which I will reserve for a future posting. (Swaziland is small, and I have to pace myself to ensure that I complete my triple-digit list of in-country destinations.)

The history of the mountain is captured in the name, and, according to local lore, many met an unfortunate end at the base of the exposed granite peak…after a bit of a freefall.

The mountain's historical significance does not stop there. Nyonyane is also where the ancient San People once lived and where Swazi royal graves are situated.

The ascent makes for a nice but challenging hike or bike, and the panorama at the peak rewards those that reach it.

There are two ways down from the Rock of Execution. I recommend simply retracing your steps.


Thursday, May 10, 2007

Ears – Three brief patient encounters

Today was all ears. My first patient had white drainage coming out of both but was too intrigued by the oversized and brightly-colored building blocks in the exam room to mind.

She liked to stack them, destroy the stack, and start over.

(Children are marvelous, resilient creatures, so resilient that they are capable of enjoying Sisyphean tasks, even self-imposed ones, while pus drips down both cheeks.)

My second patient had cemented wax blocking her ears and was having trouble hearing as a result. When I put a small plastic spatula in her ear to clear the obstruction, it made the sound of fingernails tapping on glass. Each time I tapped, she winced.

After three winces, I desisted, for I know how wince-inducing an ear excavation can be. (I always had very waxy ears as a child, and my mother is a pediatrician.)

I asked the pharmacist if we had colase, an oral stool softener that just so happens to also treat constipated ears. Unfortunately, we had none.

My expertise on compacted ear wax was not exhausted, however, and I quickly moved to plan b: I wrote “earwax removal drops” on a prescription pad and told the parents to go to the nearest pharmacy and follow the instructions on the box.

Since the blockage had left the girl unable to hear well, I wanted the parents to know how much wax they should expect to fall out before stopping the drops. I looked about the room for something the size of a large plug of ear wax when I noticed my plastic baggy of mixed nut “trail” mix. (I always get hungry mid-morning.)

“Eureka,” I thought, reaching for a raisin. I tore one of the desiccated grapes in half and found that not only does it approximate the size and shape of a glob of ear wax, but the fruit also has the same color and texture of the dry, hard, somewhat disgusting wax that was stubbornly blocking sound from reaching my patient’s ear drums.

“The drops are greasy, but they will dissolve that wax so that your daughter will be able to hear better.”

Another satisfied customer.

Qiniso, my third patient, had a thick scale covering his ears, with several small cracks in the skin. He also had significant hearing loss. The cause was unknown (probably HIV) and it was thought to be irreversible.

Qiniso was one of those kids who liked to shake hands. He is good at it too.

Qiniso’s fingers, fully extended, would barely extend beyond my palm, but he is not bothered by this.

He first gave me the typical, three-part “hello-how-are-you-I-am-fine” handshake.

Then, he began to offer me several high-fives, jumping higher and higher to reach my hand until he resorted to hanging on my elbow with his left arm while aggressively smacking my sinking hand with his right hand.

He repeatedly slapped my palm as if to say, “Ha! Gotcha! How tall and big are you now, hand!? Take that!”

Qiniso really enjoyed it. I found that it stung a bit.

After freeing myself, I sat at my desk to write a prescription for an anti-fungal (and anti-scaly-ears) cream. After a moment, with my peripheral vision, I noticed Qiniso approaching me from the right. I braced myself.

Feeling nothing, I looked up. He was holding out his hand expectantly. As I shook it, he lifted his thumb.

“I know this one” I thought, and snapped my thumb against his.

This is another typical handshake in Swaziland, one that is in vogue among young Swazi men. It is a man-to-man handshake that is usually reserved for someone that you know. Once the shake starts, the thumb snaps can continue for some time. Often, the handshake ends with the shakers actually holding hands for a few seconds, sometimes longer.

Such hand-holding is an everyday, commonplace gesture of affection between men here. This cultural nuance takes some getting used to, but there is much kindness in it.

Qiniso snapped my thumb against his about thirty million times before I reached backward with my left hand and clumsily tore his prescription from the pad. The snapping continued as I stood up, fumbled for his chart and opened the door.

Qiniso pulled me into the hall. The snapping continued.

With one firm, conclusive snap he released my hand and disappeared in the direction of the pharmacy.

Sounds of cries and laughter came from our waiting room, as is always the case mid-morning.

I wondered how much of it Qiniso could hear.


Tuesday, May 08, 2007

One hundred and one Swaziland destinations - #3: "Mealie brie drive-by"


Maize is a staple here. When still on the ear, it goes by the name “mealie”.

It is not quite like sweet corn. It is denser, heavier…and less sweet.

The roadside fire-roasted mealie is a Swazi classic. While I am sure it exists elsewhere, I have not seen it except here in the Kingdom.

Our roadside open fire restrictions are relatively lax, you might say.

So, the next time you are in Swaziland and see smoke on the roadside ahead, do not fear the worse.

Reach for spare change.

Each ear costs ~65 US cents.


Monday, May 07, 2007

The battlefield – Introducing Alshande (4 of 10)


War is a powerful metaphor, especially in places that have been surrounded by it. Swaziland has enjoyed relative peace compared to its neighbors, but the Swazi flag features a large oblong shield, and traditional Swazi attire includes a knobkerrie, a type of wooden club that doubles as a walking stick and bludgeon.

Because nearly everybody understands war, we use it frequently to explain the physiology of HIV.

When discussing the immune system with patients, we call the CD4 cells “soldier cells”, explaining that they fight the many germs that try to invade the body. Once the patient is comfortable with this analogy, I usually add that CD4’s are actually much like the generals in the army, as their primary job is to tell other immune cells how to kill the enemy. I then explain that HIV specifically attacks and destroys these important commanders, and so the immune system’s forces are weakened.

When it comes time to discuss ARVs, I explain that they work by protecting the soldier cells from the attacking virus, so the soldiers and the army can become strong again.


The Mozambican Civil War was only three decades ago, and it was not a war of leather shields and wooden weapons. It was fought with sprays of bullets, grenades, land mines, and other devices designed to penetrate flesh, be it Mozambican or Portuguese, black or white, correct or incorrect.

Over five million Mozambican civilians were displaced and 900,000 are thought to have died in fighting and from starvation.

The fighting started in Mozambique following independence in 1975. The ruling party, the Front for Liberation of Mozambique (Frelimo), was violently opposed beginning in 1977 by the Rhodesian- and later South African-funded Mozambique Resistance Movement (Renamo).
Fighting finally ended in 1992 and the country's first free elections were held in 1994.


Alshande, pictured above, was born in Swaziland seven years later to a mother who had fled the war. He was infected with HIV during birth, and when he came to us late last year, his CD4 count was 38.

Normal for five year-olds is at least 500.

If an immune system is a suit of armor, Alshande is wearing tin foil, and not the expensive, heavy-duty kind, but the cheap kind that tears too easily as you pull it out of the box.

I always ask Alshande’s mom to request me as their doc when they register at the clinic. There are two reasons for this. One, it is nice to watch the child get healthier and heavier. (He has gained three kilograms since first coming to our clinic.) Two, I enjoy speaking Portuguese, and his mother speaks little else.

Alshande arrived to our clinic with a hemoglobin of 7. This means that he was getting by with approximately half of the red blood cells of healthy five year-old, likely a result of inadequate iron intake and the long-term stress that chronic illness places on the body. (While anemia could potentially fit into the war metaphor, I usually refer to the blood being “too thin”, which works well because the Swazi diet consists largely of thin corn starch porridge. Since thin, watered down porridge is understood to be inferior to the thicker, heartier version, it follows that thin blood needs thickening.)

Two months ago, Alshande was started on iron and ARVs, and next month we will repeat his blood tests and see how his red blood cells and soldier cells are responding to treatment.


HIV will never retreat entirely from Alshande’s body. We do not yet know how to definitively defeat the virus. Our goal with ARVs is to force the bad guys into hiding so the soldier cells can replenish their numbers and go about their business of protecting the body from everyday microscopic threats.

That itself is a sizeable mission, especially in places with limited clean water and hygiene facilities.

The human body, if permitted to discreetly conduct the day-to-day battle against Nature’s intruding pathogens, mercifully graces us with the perception of health, strength, and sometimes even inner peace.

Judging from the above photo, Alshande has the potential to achieve all three.


A most unconventional war - Today's Mozambique and its HIV

Mozambique, though no longer weighed down by war, has a heavy HIV burden. Though the population prevalence of the disease is lower than Swaziland, it is a larger country, and the raw numbers are daunting. See the following articles from last month for more on HIV in Moz:

Sunday, May 06, 2007

One hundred and one Swaziland destinations - #2: "The Malolotja Nature Reserve"

Malolotja view. (Photo by Roger.)

There are many beautiful places here in Swaziland.

I had never been to the Malolotja Nature Reserve until this past weekend, despite its being but twenty minutes from my house. Touted as “the last unspoilt mountain wilderness left in Swaziland” by the guidebooks and “the most beautiful place in Swaziland” by my friend Brendan, Malolotja did not disappoint.

The photo above was taken during a hike I took yesterday.

While walking through this magnificent terrain, I had a recurring and mildly disrupting thought:
Beauty and suffering are so often neighbors; how does one reconcile the two?

Though these words seem a tad trite when I see them written down, the juxtaposition of that which is nearly perfect (yesterday’s view) and that which is tragic and painful (tomorrow’s sick children) bewilders me.

As today, the in-between day, is Sunday, I thought I’d at least pose the question.

As for Maloloja, in addition to accentuating seemingly irreconcilable realities, it also makes for a relaxing afternoon. To see it yourself, just go to where the yellow star is on the map below.


Friday, May 04, 2007

Recent Media - Food, Money, and Me

Check out the article below for an update on what is likely to end up the worst drought in Swaziland's history: Stoicism in the face of the worst ever food crisis. See also my previous entires on the topic, if interested.

To read about how global HIV spending is projected to grow in the years ahead, click here: Global Fund Aims To Triple Annual Spending By 2010.

Below is an interesting (and related) graphic from depicting the projected contribution of the USA to the Fund. Click on the graph for a better quality image.

Finally, for a brief overview of my work here as summarized in the Dukemed Alumni Newsletter, click here: Duke's Phelps Fights Pediatirc AIDS in Africa

More entries coming your way soon!


Thursday, May 03, 2007

(RED), Swaziland, Christy Turlington and You

Product (RED) GAP advert

Christy Turlington came to the Baylor clinic today.

I don’t read many of the perfumed magazines, but, as she has been on the covers of roughly a couple hundred weeklies, monthlies, etc, it is difficult not to recognize her.

In any case, she is the ambassador for (RED).

For those of you who do not know about (RED), it is an initiative to encourage consumers to buy certain product or service lines with the understanding that the (RED)-affiliated company will in turn write a check “to buy and distribute anti-retroviral medicine to our brothers and sisters dying of AIDS in Africa.”

The (RED) Manifesto (from which the above quote is taken) makes for good reading, and it is worth considering designated (RED) products when making purchases. GAP, Apple, American Express, Converse, and Motorola are examples of participating brands.

According to the (RED) blog, Christy Turlington, pictured below with Bono and Bush after an HIV awareness rally, made the trip to Swaziland to “lessen the distance between (RED) shoppers around the world and the (RED) shareholders in Africa.”

I hope they are successful, because, here in Mbabane, Swaziland, (RED) saves lives.

No matter how far away Africa seems to you, take it from me: every day, (RED) proceeds keep children from dying.

Why take it from me?

Because the "distance between" me and the “(RED) shareholders in Africa” is the length of my stethoscope.

For those wishing to know more about the initiative and (RED)’s travels in Swaziland, the (RED) blog is the place to go.

One of my favorite Baylor clinic interpreters, Lulu, is featured on the blog's April 30th entry, and just above that the author outlines how (RED) money is supporting Swaziland’s Global Fund programs.

Please check it out and do email me if you want to learn more.

Dr. Helga, Dr. Julia, Exec. Director Busi, Christy, Dr. Ryan, and Dr. Carrie. (The two children didn't give their names, but wanted to be in the photo.)

Wednesday, May 02, 2007

Bookish - Introducing Mazwi (3 of 10)


As the child pictured above walked into my exam room, he proclaimed, “My name is Mazwi. I am four years old.”

“Well, my name is Dr. Ryan. Welcome to your exam room.”

I told Mazwi’s mother how impressed I was with the child’s friendliness.

“He can write his name, too,” the mother proudly reported. “He likes to write a lot.”

The interpreter had offered the child a stuffed bear, but the child had quickly exchanged it for a nearby book. The book is called “Cloth Ears” for you child lit aficionados.

Mazwi was turning the cardboard pages, making comments to his mother in Siswati.

Mazwi is in preschool, about to start kindergarten.

I handed him my favorite Paper-Mate pen (imported from Texas) and he began to produce letters (and other shapes resembling letters) all over the exam table paper.

When I hoisted him up and placed him atop his writings to have a look at him, he did not object.

Besides cavities (most kids here have ‘em) and a common HIV-related rash called “pruritic papular eruption” (jargon that basically means “itchy rash that we don't really understand”), he looked quite well.

On ARVs, his CD4 percentage has climbed from 8 to 28.

With careful ARV administration and clinical follow-up it should remain up at least until Mazwi finishes his third novel.


Tuesday, May 01, 2007

Pivot point – Introducing Lizwi (2 of 10)


Lwizi is 6 months old.

Before he was born, his HIV+ mother received an antiretroviral called nevirapine to help prevent the transmission of the virus to the baby. The baby also received a dose after birth.

If given correctly, nevirapine reduces the likelihood of an HIV+ baby significantly. Without this intervention, 25-40% of newborns will be infected by mom.

Only about one in ten HIV+ pregnant women in Swaziland receive nevirapine.

To further reduce the risk of passing on the virus, Lizwi’s mother never breastfed the baby. Many Swazi mothers cannot afford formula (approximately USD$18 monthly), but Lizwi received it from birth.

Last month, Lizwi came to our clinic’s lab and, after a quick needle prick on the heel (like those done when testing blood sugar), our phlebotomist collected a few blood drops. They were dried and sent to a lab in South Africa where they were tested for the presence of HIV DNA.

Lizwi had tested positive for having HIV antibodies in his blood, but it was impossible to know if this was a result of his own infection or if they were mom’s antibodies, passed during pregnancy through the placenta.

I saw Lwizi in clinic yesterday. When I opened his chart, I felt a familiar adrenaline surge. It happens to me when I encounter medical tests results with mortal implications.

The results of Lwizi’s DNA test were back. My eyes scrolled down the page, looking for the word “POSITIVE” or “NEGATIVE” while the rest of me wondered what I was about to be telling the anxious mother in front of me.

Scenario #1 “The test results came back, and your baby is HIV POSITIVE. This is common among babies born to HIV+ mothers, and you did all you could to avoid transmission. Fortunately, this clinic and all who work here are dedicated to making sure that your baby receives high-quality medical care so that he can live to be a healthy old man.”

Scenario #2: “The test results came back, and your baby is HIV NEGATIVE. We will confirm this at 18 months of life to ensure that all of your antibodies have cleared, but in the mean time your baby should continue to grow and develop normally and can therefore follow-up with your nearest neighborhood health center.”

My eyes continued to scan the text in front of me. In caps print half way down the page, my eyes finally found the one word on which the life of Lizwi was to pivot.


I looked up at the baby.

He was contentedly chewing on my business card. An impressive quantity of drool was falling from the infant’s chin.

I confirmed his name, matched it to the lab result page, and gave the mom an improvised version of “scenario #2”.


There is an idiom that goes like this: “An ounce of prevention is worth a pound of cure.”

Life and death are difficult to measure, as are illness, wellness and drooling three month-olds.

But when I told Lizwi’s mom that her child was HIV free, the look on her face told me this: A healthy Lizwi is worth a heck of a lot to her.

It was a look of restrained exuberance, of gladness, of relief.

It was not the look of restrained sorrow and defeat that follows a “POSITIVE” result.

I sometimes wonder how much this sorrow would be amplified if the nearly 90% of HIV+ Swazi mothers who do not receive nevirapine knew that the drug costs a mere USD$1-2 per mother-child pair.

Less than a single British pound.

Lizwi, with my business card.