ANSWER: Swazi 'cultural competency' pop quiz (Question 4 and 5 of 10)

See below for the question.

#4 - (c) is the incorrectly worded choice. The pregnant woman, in traditional culture, would sleep by herself in the marital bed/house. The father sleeps with the children separately. The other statements are true.

#5 - (d) is correct. While (d) this may seem a reasonable reason to start fires, there seems little calculation/care involved in the modern day burning process. This was recently corroborated by two sources. One, the newspaper, which reported on the 100+ homeless families following a fire this past weekend (photo below). Several also died in the blaze, which started when small, intentional fires were spread by gusty winds. The other source is our UNICEF driver, Dumsani, who reviewed the history of Swazi burning with me as we drove to Matsanjeni yesterday. (See Swazi destination above.)

Dumsani's hypothesis was the inspiration for the last choice below. He said, "I think that, these days, many [of the fires] are started because of rage."

If this is the case, many angry folks are running around Swaziland with matches.

Swazi 'cultural competency' pop quiz (Question 4 and 5 of 10)

Answers to the following coming soon. See also patient encounters and other 'cultural competency' questions below.


www.unfpa.org

#4: Which of the following is NOT true regarding pregnancy in Swaziland?

(a) Traditional custom encourages the father to avoid association with the pregnant mother until the child is one month of age.

(b) Approximately 40% of pregnant Swazi’s are HIV+, and up to 40% of those will transmit the virus to the baby.

(c) The pregnant woman, in traditional culture, would sleep with the children in a separate building, while the father, if at the homestead, would sleep by himself in the marital bed/house.

(d) The pregnant woman, if HIV positive, is very unlikely to receive any medicines to help her prevent transmitting the virus to her newborn (12% coverage according to some estimates).

(e) According to UNICEF statistics, 74% of deliveries in Swaziland will have skilled birth attendants present.

A forest fire near Mbabane. (www.times.co.sz)

#5: This is the fire season here in Swaziland. Thick smoke fills the air and ground/grass/forest fires abound wherever you go. It is quite a phenomenon. Swazi’s have preserved this traditional practice for all of the following reasons EXCEPT:

(a) It is believed to be good for preparing the soil for planting when the rains come around September.

(b) It is easier and cheaper than cutting the grass.

(c) Charring the ground allows the cows to graze earlier on green pastures.

(d) Calculatedly lighting and carefully controlling fires on a calm day helps prevent more dangerous fires when the windy season begins.

(e) "Rage."

Beautiful and important - A brief patient encounter

Not the patient discussed below, but similar in age. (FYI: Heart sounded fine.)

The baby the mother carried in her arms was almost unrecognizable.

He had rolls of fat where once there were once skin-veiled ribs, plump cheeks where there had been cheek bones. He had a lardy tummy where once there had been a taut, protruding abdomen, an abdomen filled not with age-appropriate pudge but an oversized liver and spleen.

On does not require a healthcare background to know that the ribs of a baby should not protrude from the flesh around them. When they do, they are reminiscent of neglected, scavenging canines, drastic famine and chimney-topped concentration camps.

Any layperson will recognize that an infant without cheeks looks oddly aged. The concavities give the impression of a shrunken elder. The eyes sink tiredly into the sockets, as if completing life’s journey rather than just beginning.

When the sharp, defined angles of the infant skeleton are juxtaposed with a belly that looks and feels like a volleyball, the visual effect is grotesque. The proportions are similar to a miniaturized pregnant woman at term, the baby a crude caricature of his own recent birth.

The mother entering my exam room cradled the chubby, full-faced baby in her arms. Her face held the glowing, humane expression of a loving mother holding her beloved baby.

If a cosmetics company could manufacture and package that glow, it could name any price.

“How are things going?”, I asked the glowing woman.

--

Even before medical school, I learned the value of open-ended questions. They allow the person asked to answer without being limited by the intent of the question. In a way, it allows the person asked to choose a question, and then answer it.

In the doctor-patient encounter, potential answers to the question “how are things going?” include: “good”; “oh, not too good, doctor”; “it is very cold outside”; “my husband lost his job”; “the baby is too too sick”; “I don’t know”; “you tell me”; etc.

By far, the three most common answers are “I am fine”, “she is fine” and “he is fine.”

This is the benefit to asking open-ended questions when your HIV positive patients have been receiving appropriate antiretroviral therapy. The Baylor clinic has been open a year and a half now, and most all of our previously “too too sick” patients are quite “fine”, indeed.

Alternatives to open-ended questions are many, and include “Does the baby have fevers?”, “Your chart says you are just here for a refill. Is that correct?”, “Is there anything about the child that I should know?”

These questions hasten the visit, corners the parent into giving narrow responses, and ensures that the doctor will miss things, usually the important things.

--

“How are things going?” I asked the glowing woman.

This was her answer, in translation:

“Well, Doctor. Before, I did not want to bathe my child in the homestead because his skin was bad and his belly was sticking out. People did not like to look at him. They did not come near us.”

“Now I bathe the baby outside as much as I can. Everyone wants to come up and touch him. They want to tell me that he is beautiful.”

My job – A patient encounter

When I ran short of breath mid-sentence, I was caught off guard.

I was not saying anything that I had not spoken a hundred times.

Still, after the words, “It is my job to…” I had to stop.

You see, when discussing HIV with a recently diagnosed HIV+ 11 year old child, I prefer to keep things upbeat. The more reassuring and routine the chat, the better.

It is no time to gasp, whimper, or sob, for no child will interpret these emotional sounds as reassuring.

Siyabusa had been brought to the Swaziland Baylor Center of Excellence by three ex-patriots who run a near-by orphanage. Well, not so near. They had awoken at 4:30am so that they could make it to the Baylor Center of Excellence before seven. (They were eighth in line.)

The child had been moved to the orphanage the evening before because his mother was coinfected with HIV and tuberculosis, very sick, and unable to care for him.

Siyabusa spoke no English but was handling the transition well. Upon arrival to the orphanage, he had been excited to learn that he would be receiving not one, not two, but three meals a day, and that he would have help cooking them.

Siyabusa’s body was covered with scabies lesions. Many were bloody or scabbed from his scratching. The month prior, he had been in the hospital for scalp abscesses. Fortunately, the remaining hair hides most of the scarring.

He is a mild-mannered boy. He smiles readily. His face is thin, his eyes fixed on me and the translator, his gaze reverent but hungry.

No, I would not let this child see me cry.

After Siyabusa entered the exam room, it took no more than five minutes to address his medical problems. A mild bacterial pneumonia and severe scabies required two medicines and an x-ray. I added a third drug for the incessant itching. His left eye was infected with another type of bacteria and required some eye drops. Finally, he would receive multivitamins and routine prophylaxis with cotrimoxazole (Bactrim) until we knew his CD4 count.

That was the easy part.

“Does Siyabusa know about his status?” I asked the caregivers.

“No” was the collective response.

“Siyabusa, are you sick or healthy?”

Lulu translated.

“I am often sick,” Lulu said, translating his response.

“Do you want to grow up and be a strong, healthy man?”

“Yes.”

“I want that for you too.”

I then asked the child if he knew what a soldier cell was.

He did not.

I explained to him that it is a cell that fights bad germs in the body, just like a soldier fighting in a war. I told him that soldier cells, also called “CD4 cells”, keep the body healthy.

He nodded.

I told him that we were going to check his blood to see if his soldier cells were many or few. If they were few, then we would help him build up the army so that they can keep his lungs, skin and eyes healthy.

I asked him if he had ever taken medicine. He said that he had taken medicine for the infection on his scalp. I explained that there are also medicines that help the army of soldier cells get stronger so that Siyabusa could also get stronger…and healthier…and bigger.

“If your soldier cells are low, we will give you this medicine.”

He nodded.

To ensure that he got it, I asked him, “Do you want your soldier cells to be high or low?”

“High,” he said, his eyes fixed on me to make sure that he was correct.

I gave him a congratulatory high five and said, “It is my job to…”

When I ran short of breath mid-sentence, I was caught off guard.

The remainder of my sentence was imprisoned somewhere between my lungs and larynx, and in their place salty water was being freed onto my eyeballs.

I was unsure if I was happy or sad, clueless whether I was experiencing an instant of confusion or clarity. All I knew is that I wanted the freedom to choose my words, speak them, and reassure this scarred, itching child with a dying mother. I wanted him to know that, though before last night he ate only once a day, he deserved three meals daily, and snacks. I wanted him to understand that, though his skin was infested with mites, his hair patchy, and his left eye red and swollen, he did not deserve the scabs, scars, and conjunctivitis.

I scanned the room to spread out the clear teary fluid that was pooling in my own eyes so that it did not fall and betray my message of reassurance. I swallowed hard and breathed in slowly in an effort to regain control of my throat and lungs.

I then began again.

“Siyabusa, it is my job…to help you keep your soldier cells high. Can you come back next month and help me do that?”

“Mmm.” He said in affirmation.

“Yes, he can,” the translator echoed.

Another high five.

Siyabusa stood up to go and, as I shook his hand, I felt the coarse scabs and burrows of the scabies mite close around my fingers. With his other hand, he scratched his stomach.

“Good luck in your new home. See you soon, Siyabusa.”

He gave me an upbeat, reassuring smile and followed the ex-pats to the pharmacy.

I smiled back. It was one of those deep, what-a-gift-it-is-to-be-here-and-now smiles. I wear it still as I sit here and marvel at the fact that I get paid to help Siyabusa and others like him get their CD4 cells back.

ANSWER: Swazi 'cultural competency' pop quiz (Question 3 of 10)

Here are the answers. See below for the question.

Chakalaka = (b)
See my previous entry One hundred and one Swaziland destinations: Chakalaka for more.

KFC = (b)
Yes, it is here, but it costs most Swazi’s 1-2 days wages.

“Seswaa” = (c)
Boiled, pulled beef, a common food in Botswana. I had this for the first time last week. (Thanks to KT, my colleague from Bots.)

Sushi = (c)
This may look like Tokyo’s finest, but we had to import several ingredients and make the rolls from scratch. See Japanese brunch in Swaziland - An exercise in culinary syncretism.

Trout = (c)
Not in Swaziland. Zululand (in South Africa) and the Drakensburg Mountains are your nearest options for these fresh-water fish.

Pap = (a)
This one is a local staple. It is relatively inexpensive, made from maize meal. When mothers run low, they add more water to make a thin porridge to quiet the kids. See Leaving on a jet plane, and stuffed for the original post.

Eggs, PB, beans lentils = (a), maybe this year (b)
This is a photo of what I call the “strong foods”. I review these with my patients whenever a child is not gaining weight, for they are high-cal, relatively inexpensive options. With this year’s drought, prices are up and the strong foods harder to get. Read my post Whispers and averted eyes if you want the story behind the photo.

Wors = (b)
Meat (in this case sausage) is also a strong food, but beyond the monetary reach of the vast majority here.

Butternut = (a), sometimes (b)
This squash is a common food, but can be expensive if out of season. It makes a sweet pumpkin mash or soup, often served with cream and cinnamon (if available). See my Gardening in Swaziland link, where I brag about my green thumb.

Barracuda = (c)
This fish fillet is found along the Mozambican coast and is delicious. Seafood in Swaziland is hard to find and very pricey.

Corn Soy Blend = (a)
The World Food Program distributes this powder around Swaziland. All children on ARVs or TB medicines through our clinic leave with a bag of CSB. See Broth, no bread – A patient encounter and Today's family photo(s) – Powdered foods for more.

Fish and chips = (b) Again, meat is expensive. Few have it except on special occasions. This dish, as you might guess, was imported by the Brits, whose protective role in Swaziland dates back to the rise of the neighboring Zulu nation, at the time a grave threat to the Swazi tribe. (Pardon the broad historical brush strokes...I am not well-studied in Swazi-British history.)

Mealies = (a) These are common along the road and cost the equivalent of 30 cents US. Each ear is a meal. See One hundred and one Swaziland destinations: Mealie brai drive-by.

--

Ok. The number and distribution of the (a)’s illustrate that, essentially, Swazis subsist on maize and other vegetables when in season. Beans and maybe dairy products offer occasional protein.

The feast of photos from the previous post reflects the foods that this over-privileged ex-pat doctor (and other well-off Swazis) have eaten over the past year, and is in no way representative of the menu in a typical local household.

Food, you see, is at the top of the long list of inequities in this country.

Swazi 'cultural competency' pop quiz (Question 3 of 10)

There has been a lot of talk about food in Swaziland recently. Of course, malnutrition is widespread here, its treatment a regular component of our clinical practice. I will talk a bit more about the drought soon, but I wanted to ask a culturo-culinary question to set the stage.

Those of you who frequently visit this website will have an advantage here as I post comments and photos of local food quite frequently.

Ok.

Please classify the thirteen pictured foods as (a) ubiquitous in Swaziland, (b) available in Swaziland, but unaffordable by most all Swazis (c) nowhere in Swaziland. If you email me your answers (or leave them under comments), I will reward the winner with public praise. My email address is messageforryan@gmail.com.

Answer soon.

Very very fine despite the thing – A patient encounter

www.inkycircus.com


“When are you going to find a cure for this thing?” the mother asked softly, leaning forward. Her elbows came to rest on the fabric of her traditional red, white and black skirt, patterned with images of Swazi shields and King Mswati III’s.

“HIV?”

“Yes, HIV.”

The word “thing” is actually quite fitting, I thought. An appropriately nebulous term, a vague, generic word that could refer to any‘thing’, especially those one of those things that one hesitates to actually name, one of those taboo-laden nouns that sound and feel better when muttered euphemistically.

In Swaziland, the thing is often spoken of in nicknames and whispers, and the whisperers are nearly always terrified.

They are terrified because they believe that it is deadly, cure-less.

“I have no idea whether we are going to find a cure for this thing any time soon,” I confessed. “But, there is good treatment...today.”

“I know!,” the mother proclaimed. “When you were not here, I thought I would lose my child.” Her eyes glimmered and then lifted from their downward gaze and met mine. “Now with the clinic she is fine. Very very fine.”

I looked at the child sitting in the chair next to the shiny-eyed, beaming mom.

She looked fine indeed, no longer skeletal, dull-eyed, with a mouth full of cottony thrush, no longer how she was before the thing had been outwitted by an combination antiretroviral pill taken twice daily.

Her gray and maroon school uniform was clean and carefully pressed, her chin upright.

She had a smiley face sticker on her forehead, the preferred place for colorful adhesives after having blood drawn here in Swaziland.

“Let’s keep you healthy until the cure exists," I suggested to the child.

“Yes, doc, let’s do it,” the mother chimed.

“Don’t miss any doses, ‘kay?” I said to the young girl.

“I will not.”

“She never does,” the mother said proudly, beaming again.

One hundred and one Swaziland destinations- #12: My workplace

This is the Baylor Center of Excellence, Swaziland. In a few weeks, I will have hung my hat (and white coat) here for a full year.

Well, I don't actually wear the coat, as it dirties easily and scares the under fives.

Within the building pictured, we do all we can to offer excellent care and treatment to HIV positive Swazi children and their caretakers.

If you were a fly on the wall of Exam Room 6 at the Baylor COE, you might see this:

Exam Room 6.

Of course, we would not be posing.

Rather, Lulu, on the left, would be translating for me as the gogo, in the center, is unlikely to speak much English. The child (HIV positive or exposed, very sick or quite well) would likely be eyeing me with some mistrust, similar to the facial expression captured here.

As a fly on the wall, you would often not see the mother or father in the room, for they are often working, sick, or deceased.

As I have discussed in previous posts (such as "Ticklish - A patient encounter") grandmothers are frequently surrogate parents here in Swaziland.Of all Swazi destinations that I have been fortunate enough to visit, none leaves me feeling as fortunate as this Baylor clinic.

There are flies on walls all over Africa (and, for that matter, Texas), and, if those insects could blog, few would report sights as hopeful as those of Exam Room 6 at the Baylor COE.

It is a place of hope, and I would rather work there than most any place.

ANSWER: Swazi 'cultural competency' pop quiz (Question 2 of 10)

Answers to questions below as follows:

2a. False (chain link fence ~6ft tall)
2b. F (pic taken at water’s edge, where crocs eat)
2c. F (reminds me of that game “hungry hippos”, and I am one of the marbles)
2d. True (the 16 inch wall between me and the most deadly of the big 5 was some comfort, though.)

Pardon the melodrama. It's just that I like my place at the top of the food chain, and sometimes here in Africa I feel temporarily displaced.

More Swazi 'cultural competency' questions soon.

Swazi 'cultural competency' pop quiz (Question 2 of 10)

True or false:

The photographer taking the photo below has kept a safe distance from the wild, deadly animal.



The photographer taking this photo has kept a safe distance from the wild, deadly animal.


The photographer taking this photo has kept a safe distance from the wild, deadly animal.


The photographer taking this photo has cleverly placed a subject between him the wild, deadly animal to ensure that he is not the first to be trampled.


Answers (and more nuanced questions) coming soon.

ANSWER: Swazi 'cultural competency' pop quiz (Question 1 of 10)

The answer to the question below is, of course, is “all of the above.”

The questions will get more difficult. I do not want to insult my vast, erudite readership.

In review:

Choice A is common knowledge.

Choice B is discussed in a previous [somewhat lengthy] post called The mysterious noise – An [auditory] patient encounter.

Choice C hearkens back to my inability, despite much searching, to find ethnic dolls when holiday shopping last year. I haven’t figured it out.

Question #2 coming up.

Swazi 'cultural competency' pop quiz (Question 1 of 10)

Sihle.

The pediatric patient pictured above (named Sihle) is demonstrating:

(a) The tendency of young children to want to mimic the behavior of their parents
(b) The most common method used by Swazi mothers when toting around toddlers
(c) That, despite the epidemiology of Swaziland, there are very few dolls that do not appear 'Caucasian' on the local market
(d) All of the above.

Answer coming soon...

Swazi HIV Awareness Poster Series (10 of 10)

What am I up to? (7 July), continued

Black mamba.

There are 15 deadly snakes in southern Africa, more or less. Saturday, I learned about the Black Mamba, Green Mamba, Cape Cobra, Snouted Cobra, Angolan Cobra, Black Spitting Cobra, Forest Cobra, Mozambique Spitting Cobra, Zebra Spitting Cobra, Black-Necked Spitting Cobra, Rinkhals, Puff Adder, Gaboon Adder, Boomslang, and Twig Snake.

It is said that Swaziland serpent bites are usually due to the Puff Adder and Mozambican Spitting Cobra. Black Mambas are around, but this legendary animal (said to be able to outrun a horse) does not usually sleek around looking for a fight….nor can they (max speed 20km/h) catch a healthy horse (73km/h).


Puff adder.

The Puff Adder is a short, fat snake around a meter long. It looks somewhat like a rattlesnake, but instead of diamonds it has chevron-shaped lines down the back. And no rattle. It gives birth to live baby snakes (20-40 per ‘litter’) and it gets its name from its tendency to breathe in and exhaling forcefully through its nostrils. As you may guess, that makes a hissing noise.

When this one bites you, you can look forward to the skin around the fang marks hurting, swelling, then turning black and dying. One component of the venom causes the blood to lose its ability to clot, and so copious bleeding at the site and into the skin is expected.


A dramatic example of the effect of "cytotoxic" venom, like that of the puff adder.

The Spitting Cobra (and another local snake called the Rinkhals) have fangs that open forward, allowing them to eject a thin jet of venom in the direction of the attacker. They typically aim high, around the eyes, and the stream is designed to break into small droplets, a sort of less-than-refreshing poison spritzer to the face. Their range is impressive, approximately 2 times the length of the snake.

--

For those of you who read my recent blog entry about Sibebe Rock (Swazi destination #10, I believe), I did not mention that, due to the harrowing incline on the way up, we descended through waist-high grass on an alternate route down. I sent the dogs ahead for snake patrol, but, I must say, on our next Sibebe hike, I might prefer risking tumbling down the granite to these fanged locals.

What am I up to? (7 July)

Mozambican spitting cobra. (www.geocities.com)

What do a Mozambican spitting cobra, a black mamba, and a puff adder have in common?

(a) They all spit venom
(b) They all live ‘round here
(c) They’ve got fixed (as opposed to 'hinged') fangs
(d) Their venom kills by disabling your all-important neurons

Stay tuned for the answer. I am taking a course on southern Africa’s most venomous snakes today.

Tomorrow is the snake handling portion of the course.

Swazi HIV Awareness Poster Series (9 of 10)

"because...my future is mine"

Broth, no bread – A patient encounter

There was an old woman who lived in a shoe
She had so many children, she didn't know what to do
So she gave them some broth without any bread
And kissed them all quickly and put them to bed.

--

“Do you have food in the house?” I asked.

“No,” the gogo replied.

This explained the child’s malnutrition, which was moderate (defined as less than 80% of expected weight for height).

“Do you have support?”

“Yes, but there are many children in the house.”

“How many?”

“Sixteen.”

“Sixteen?”

“Sometimes seventeen.”

With a denominator of seventeen, the numerator has to be a heck of a lot of food.

There are few households here in Swaziland with a heck of a lot of food, and it is a common practice to water down maize meal and serve it as a porridge to children.

After initiating the child on ARVs and discussing possible solutions to the food shortage (alas, there were few), we gave the gogo a large bag of World Food Program corn-soy blend.

Large bag of CSB/17 = something.

Something is better than nothing.

Something. (Corn-soy blend.)

Happy Independence Day, y'all

Two Denisonians (Ryan and Matt).

My hometown of Denison, TX is a town of 23 thousand folks, at least last time I checked.

We call ourselves ‘Denisonians.’ Until yesterday, I was under the impression that the only Denisonisans that were destined to visit Swaziland were my mother, father, sister, brother and I.

I was wrong.

I realized I was wrong when I came face to face with Matt Dobson in the Baylor clinic’s staircase yesterday.

Matt Dobson is a Denisonian. His family and mine go back decades, and his older brother (Dan Dobson) and I accounted for approximately 99% of the mischief that took place in the Denison High School “gifted and talented” program. (How we were allowed in a program so titled…and allowed to stay in that program…I will never know.)

Looking back, I am not terribly proud of [most of] my behavior, but Dan and I kept things, er, interesting, though our ‘gifts and talents’ in those days, at least those we most often showcased, were not necessarily academic or, shall I say, entirely upstanding.

It was all, of course, legal.

These days, the Dobson brothers, like myself, seem to have mainstreamed to some degree.

We have also earned degrees.

Dan is now an expert on legality and works as a patent lawyer in Washington, DC and Matt is starting a job at the US Department of Justice after recently finishing his MBA at the Kellogg School of Management in Chicago.

Matt was traveling with a group from Kellogg who are hoping to, among other things, develop point of care (i.e. on-site) HIV diagnostic testing, including viral load and DNA PCR.

I hope they succeed, for such tests would revolutionize our work here.

Speaking of revolution, happy 4th of July.

There are several reasons to celebrate this day. Though there are few Denisonians in these parts, I meet people like Matt all the time here in Swaziland. Every single person that I have met traveled here because she or he wants to help.

That, in my opinion, is a compliment to their homeland, a tribute to that vast acreage beneath the star-spangled banner.

One hundred and one Swaziland destinations- #11: Sibebe Rock

Sibebe Rock.

Sibebe Rock is the largest granite outcrop in the world. We climbed it Sunday.

It was steep.


Dr. Dan Dewey



Dr. Dan Dewey's dogs and Ryan.



Granite and Ryan.



A flowering plant on Sibebe.

Swazi HIV Awareness Poster Series (8 of 10)

Recent Media - Preventing steps back

www.nytimes.com


For each sub-Saharan African who was placed on anti-AIDS drugs last year, five more were newly infected, and still the coverage to prevent new cases remains ‘ridiculously low.’ Read more at the link below, and don’t skip over the paragraph of the article that states, “Fully 28 percent of those who need [ARV] treatment get it, compared with just 2 percent in 2003,” for that increase of 26% is something to be proud of, something to build on…while continuing to bolster prevention efforts.

New AIDS Cases in Africa Outpace Treatment Gains
(I recommend also browsing the article photos if your internet speed allows it.)

The Houston Chronicle recently published a story (link below) that outlines the Baylor International Pediatric AIDS Initiative’s newest international partner—Kenya. The clinic there will join the existing BIPAI pediatric HIV care and treatment clinic network in Africa, the largest of its kind in the world (see map below).

Another step forward for Baylor AIDS Initiative in Africa.