The un-barefoot doctor: My Swazi half marathon - Cultural encounter series (2 of 10)

I ran a half marathon last Saturday, the "Standard Bank Slojos Half Marathon", to be exact.

Some of the competitors wore the latest running apparel. Others wore dilapidated Converse high-tops and worn-out khaki pants. Some ran in bare feet.

Most of the competitors were Swazis. Some were from neighboring countries (South Africa, Zimbabwe, etc.)

The course was about a third dirt road, two thirds pavement. Hills there were plenty.

The highlights of the race for me were two:

1) Running km 14-16 with Goodness, a barefoot Swazi women around twenty years old. She spoke to me in easy, full sentences and ran the downhills fast, claiming that she could not slow down. I have never run shoeless down a gravel road, but, if I did, I would do so slowly.

2) Handing out chewing gum to the kids on km 17, after several volunteers gave me two handfuls. As I cannot long-distance run and chew gum at the same time, I tossed them one at a time to the clapping, waving, singing, dancing, and sometimes just staring children that stood in groups along the road every few hundred meters. They not only reminded me why I was in Africa to begin with, but provided me with a much-needed distraction from the inevitable pain experienced when running just a little bit too far.

Speaking of which, the Nedbank Soweto Marathon is November 4th. I just registered. Registering, of course, is the easy part.

Why I love my job - Quote 14 and 15 of 20

Romanian patient with bilateral parotid enlargement due to HIV.
(www.bayloraids.org/atlas/)

“He was so big here.”

-Mother of 7 year-old Zinhle. As she made this statement, she held her hands up to her ears like earmuffs. She was referring to the child’s parotid glands, which had been enlarged prior to starting ARVs in September 2006. (An example of this is shown in the photo above.) Now, no earmuffs.

“He spoke nothing before. Now he is starting to speak.”

-Mother of two year-old Siphiwe, who started ARVs in June 2007. This is the third patient I have had this week alone whose language skills advanced dramatically after ARVs.

(See quotes 12 and 13 for the other two.)

Stories about Sipho - A guest-blog patient encounter

If interested, please have a look at my recent patient encounter narrative on the (BLOG) RED website.

For those unfamiliar with (RED), you can read plenty more on my May, 2007 blog post and at http://www.joinred.com/.

One hundred and one Swaziland destinations - #18: "Mantenga Falls"

The falls.



My first lap in the pool at the base of the falls.


I had not confirmed that there were no crocodiles in this segment of the Usutu River at the time this picture was taken, and so the pictured lap was my only lap for the day.

I have since confirmed that there are many crocs in the Usutu River, but not near Mantenga Falls. I have also heard from several reputable sources that that there has never been an incident in this section of the river and that crocodiles do not like turbulent water or rocky river banks.


As I am now reasonably convinced that there is no large scaly greenish sharp-toothed underwater carnivorous link in the Mantenga Falls food chain, I have since been in the water several times, usually with friends. (Even a single decoy doubles my odds of survival, if I did the math correctly.)


Mantenga Nature Reserve, where the falls are situated, is nestled between the two mountains, one aptly called "Sheba`s Breasts" and the other "Execution Rock", featured previously as Swaziland destination #4.


Below the Mantenga Falls there is a village of traditional Swazi beehive huts and traditional Swazi dances are performed twice a day.

Swazi HIV Awareness Poster Series (11 of 20)

Why I love my job - Quote 12 and 13 of 20

“The first time I came here…eeesh…it was a problem. He couldn’t talk at all.”

A mother explaining how her 8 year-old began to learn how to speak after starting ARVs at age 7.

--

“She tells me in SiSwati when she poops herself.”

A mother marveling at the fact that her nearly three year-old daughter has begun to use words after starting ARVs a few months ago. She never spoke prior to starting the medicines. (She also knows several other words besides "poop".)

--

You see, HIV, when allowed to replicate freely, is very hard on the developing brain.

Me? Know it all? Now that's funny! - A Sept-Oct disclaimer

This is a popular review book for the pediatric board exam. So far, it made me laugh once. No, twice. Well, the second was more of a semi-amused exhale.

Oh, the name of the test should be capitalized, I think. Fitting, for it is a capital pain in the [neck] to study for. A friend of mine recently told me, "It should be a pain in the [neck]...you take care of kids!"

I suppose he has a point. In any case, on Oct 15-16, I will be filling in multiple choice boxes to prove that I will not carelessly choose B when my real-life child-patient needs A or perhaps D.

Though I would rather be telling friends and strangers about my real-life Swazi patients and sundry misadventures, for the next two weeks I am more likely to be not-laughing than writing.

Just thought I'd let you know. Do drop by the site, though, just in case I suddenly know it all and am able to tell a story or two.

Why the chicken crossed... Swaziland destination #16 addendum

This narrative below is a follow-up from the previous two entries regarding Swazi destination #16, Lomahasha (red arrow on above map).
--

The four chickens’ heads bobbed slightly with each step the ladies took. The women were almost to the kitchen, two chicken legs (and one down-side-up chicken) in each hand. The doomed necks of the chickens were contorted maximally in an effort to correct the inverted horizon, giving all four animals a proud, distinguished appearance in their final minutes. The birds looked remarkably calm as they disappeared into a hut of clanging pots and women’s voices. Smoke rose slowly into the hot, dry air from a chimney-pole above.

The scene, as witnessed through the Lomahasha ART exam room window, made me question the appropriateness of the oft-used adjective “chicken”.

It is not easy to be a domesticable, tasty forager in a hungry, unjust world.

It is also difficult to be a patient in Swaziland. Human beings packed the hallway outside the exam room like a rush-hour subway car. Nikiwe and I could not actually open the door to leave. We would literally have to work our way to freedom.

Until the vehicle with our chart and medicines arrived, however, we could do nothing except chat and wait. Despite copious schooling, I am useless without patient records and ARVs.

As Nikiwe and I discussed some of the differences between Baylor clinic and the rural government health clinics (there are several), three bleating goats and three languid donkeys passed by the window. As I reviewed our plan to slowly transition out of Lomahasha and begin mentoring at other rural clinics, six right-side-up, naïve chickens strutted past. Eventually, we heard the louder, mechanical cackling of a diesel engine. The welcome sound preceded the Ministry of Health vehicle itself by sixty seconds and a large plume of dust by sixty-one seconds.

We saw twenty-five patients in the following four hours. Nikiwe did all of the real work, consulting me occasionally.

While the Baylor doctors will miss the farm life surrounding the Lomahasha clinic and the people within, we will be shifting our attention to another site soon. The queue of sites awaiting mentoring is long.

After we saw the last patient, I told Nikiwe, “That was not so bad.”

"No, it wasn’t" was her reply.

Nikiwe (pictured below) is the last of the three nurses to receive one-on-one teaching in pediatric HIV care, and is prepared to provide pediatric ARV care independently. When children need ARV initiation or when complicated cases arise, she will refer them to Baylor or nearby Good Sheppard Hospital.

One hundred and one Swaziland destinations - #17: "Lomahasha"

My apologies, but I do not have time to attach much text to these images (tomorrow, maybe). They are a follow-up to the Swazi destination posting a few days back. Stay tuned for more.


The Lomahasha Clinic, serving one of Swaziland's many peripheries. It is one of our outreach sites, approximately 2 hours from Mbabane.


Signage in Portuguese, as the region abuts Mozambique.


The landscape.


The black mamba that the car in front of us ran over. The snake was moving between cane fields at an inopportune time. (Sad, yes, but they are neurotoxic.)

This was the second 'wild' black mamba that I have seen in Swaziland. Maybe I can tell you the story of the first soon.

Pathologic pick-a-boo - A patient encounter, Part 2

Do read Part 1 first. (See below.)

“Will he understand?”

“Probably so,” I answered. “If not, we can review it each time he is here so that he knows more about why he is taking the medicines."

I turned to the young child. He was seated on a black plastic and metal chair. I envied his posture. Looking at him, I began to also envy his style. He wore a pressed, red and white, short-sleeved, plaid, button-down shirt and baggy khaki pants, the kind with plenty of extra pockets.

“Monde, how are you today?”

“I am fine,” he said.

I gave a hyperbolic fist pump in the air, the celebratory and mildly obnoxious kind.

Monde smiled. It was an ungnarled smile. His brown irises were centered perfectly and still within paper-white eyes. His cheeks were full and wartless.

The TB soup around his brain was gone, and he had the face of a child again.

I talked to him about his soldier cells and how they were getting stronger on ARVs.

“The soldier cells were three [percent] before, and they are now six! Imagine when they get to ten, or even twenty! You are going to be very strong.”

I dramatically flexed my arms to show him how strong he was going to be. (Don’t roll your eyes, dear reader; kids like that kind of stuff.)

When I finished 'HIV-for-seven-year-olds 101', I asked Monde's mother if there was anything else.

“I told Monde that he would be on the medicines for life,” she responded.

I extended my arm, holding out my clenched fist; Monde did the same, hitting his knuckles softly against mine.

“Well, that is going to be a long time."

Pathologic pick-a-boo - A patient encounter, Part 1

I first met Monde in the hospital. Well, we did not meet.

Let me start again.

I first saw Monde in the hospital. He did not see me.

As I approached the foot of his bed, his head was turned to the left as if he needed desperately to peer deep into the stained, foam mattress beneath him. The dark brown of his eyes had disappeared into his sockets, where they fluttered in and out of view.

His eyelids were quivering as well.

These were not the rhythms of healthy eyes. Monde had tuberculosis living in and around his brain and spine.

His twitchy-eyed face was covered with flat warts and his weight was 60% of what it should have been.

He wore a hospital gown, though there was little flesh to cover, little dignity to preserve.

His mother sat at the bedside, looking at him with what I would describe as bewilderment and intrigue. Wonderment, even.

The expression on her face asked, “Is this skeletal, distorted, jerking child actually Monde?”

I was not optimistic that he would survive. His CD4 count at the time was 3%, making his immune protection analogous to sky-diving with a cocktail umbrella or, perhaps, Nascar racing with whoopee cushions for airbags.

While the TB and HIV thrived behind his unseeing, darting eyes, Monde was dying.

(Gotta go study. To be continued tomorrow. Don't worry, the story is a happy one.)

One hundred and one Swaziland destinations - #17: Lomahasha

Nikiwe and me.

The photo above was taken last week when I traveled to Lomahasha and mentored Nurse Nikiwe.

More on that soon.

Happy Swaziland Independence Day

www.nationalgeographic.com

Today marks the 39th year of Swaziland's independence. For those interested to know about the events leading up to the Kingdom's official autonomy, I have included a summary below.

"According to tradition, the people of the present Swazi nation migrated south before the 16th century to what is now Mozambique. Following a series of conflicts with people living in the area of modern Maputo, the Swazis settled in northern Zululand in about 1750. Unable to match the growing Zulu strength, the Swazis moved gradually northward in the 1800s and established themselves in the area of modern or present Swaziland.

They consolidated their hold under several able leaders. The most important was Mswati II, from whom the Swazis derive their name. Under his leadership in the 1840s, the Swazis expanded their territory to the Northwest and stabilized the southern frontier with the Zulus.

Contact with the British came early in Mswati's reign, when he asked British authorities in South Africa for assistance against Zulu raids into Swaziland. It also was during Mswati's reign that the first whites settled in the country. Following Mswati's death, the Swazis reached agreements with British and South African authorities over a range of issues, including independence, claims on resources by Europeans, administrative authority, and security.

In the early years of colonial rule, the British expected that Swaziland would eventually be incorporated into South Africa. After World War II, however, South Africa's intensification of racial discrimination induced the United Kingdom to prepare Swaziland for independence.

Political activity intensified in the early 1960s. Several political parties were formed and jostled for independence and economic development. The largely urban parties had few ties to the rural areas, where the majority of Swazis lived. The traditional Swazi leaders, including King Sobhuza II and his Inner Council, formed the Imbokodvo National Movement (INM), a political group that capitalized on its close identification with the Swazi way of life.

Responding to pressure for political change, the colonial government scheduled a popular election in mid-1964 for the first legislative council. The INM and four other parties, most having more radical platforms, competed in the election. The INM won all 24 seats.

Having solidified its political base, INM incorporated many demands of the more radical parties, especially that of immediate independence. In 1966, the UK Government agreed to discuss a new constitution, and a constitutional committee agreed on a constitutional monarchy for Swaziland, with self-government to follow parliamentary elections in 1967.

Swaziland became independent on September 6, 1968."

http://en.wikipedia.org/wiki/History_of_Swaziland

Ode to Dan and Teena

L to R: Ryan, Paul, Beth, Antz, Michelle, Dan, Teena, Carrie, Dave, Anouk.

Dan Shodell (white shirt) and Teena Sebastian (pink bandana) are officially moving from Swaziland to Mozamique this week.

They not only organized the first recorded Swaziland ultimate frisbee league (pictured here after playing yesterday), but also worked diligently over the last year for the children of Swaziland. They are good folks and good friends.

Dan worked in PMTCT here in Swaziland (for EGPAF) and has recently taken a job with the CDC in Moz, also focused on HIV prevention. Teena is remining with Baylor and estalishing a new outreach mentorship program near Maputo.

They are expecting a baby girl soon.

Today’s photo(s) from the Cape: Apostles and sushi – 9 and 10 of 10

I left the Cape and my vacation behind a couple days ago. Thank you Catherine, James, and Eric, for a lovely week.


I gave sushi-rolling lessons my last night. Cheaper and much more fun than letting the guy behind the counter do it.


Yours truly with the first 2 or so of Cape Town's "12 apostles" in background.

Now, back to work.

Colorful, dancing virgins- Swaziland's Reed Dance

Swazi girl.

Today is the day of Swaziland’s annual Reed Dance, or "Umhlanga." Click here for my entry on last year's event. The procession is steeped in tradition and so varies little year by year.

Oh, and happy Labor Day to those of you celebrating that other holiday.

Today’s photo(s) from the Cape: Come rain, come shine – 7 and 8 of 10

Today’s photo(s) from the Cape: Camps Bay – 6 of 10

A year and change - TV MDs and me

I do not have TV in Swaziland. Here in the Western Cape, there is cable. This being the case, I spent two hours the other night watching actors scurry around in white coats throwing around medical jargon and courting each other.

One hour-long show was the one where that angry, mean fella uses death-defying clinical intuition to make diagnoses so buried in red herrings and esotery that only the screenwriter has any clue what the actor-patient has.

The astute doctor-actor-jerk who stars is riveting as you never know who he is going to calculatedly heal or offend next. His name is Dr. Hose or something, and he is addicted to narcotics. The episode I watched ended with him getting arrested.

The other hour-long show was the one with all of those pretty, romantically intertwined folks that all seem to be simultaneously training to be pediatricians, internists, obstetricians, surgeons, and courtroom defendants. A hospital, with its mortality, humanity, and politics, makes for a superb soap opera backdrop.

I must confess that I found myself especially vulnerable to the tear-jerking, heart-string-pulling plots of these telenovelas, for they are quite reminiscent of my five years of academic clinical training, excluding the overacting and fickle romance.

The shiny hospital floors and big glass windows. The lily-white walls. The cornucopia of doctors and nurses so plentifully stocked that they have time to joust for ego points and lovers between seeing patients.

It all made me the slightest bit homesick. It is a sensation of vague yearning, the kind one gets when missing things that he or she doesn’t remember all that well.

As I write this, I have been in Africa for one year and change.