Tuesday, November 27, 2007

Why I love my job - Quote 20 of 20

“He is gaining weight. He is eating too much. His stomach is too big!”

This was the response when I asked how Sinethemba’s mother how her son was doing.

His belly, medically speaking, was not actually “too big”; it was just no longer a concavity beneath his protruding ribs, as it had been before ARVs.

It now looked like a two year-old’s belly should look: convex.


Monday, November 26, 2007

Why I love my job - Quote 19 of 20


“Buya,” loosely translated, means “come.”

The 2 year-old girl in pink who was supposed to "buya" was carrying a gigantic bag of puffed corn that, if empty, might be able to contain her. She was shoveling the junk food into her small mouth with noteworthy determination.

When her brother said this word, the girl protested but did not resist too vigorously, for fear of spilling. With some degree of effort, the boy, about 4 years old, managed to pick her up and carry her toward the phlebotomy room. (She did not know where she was heading, or perhaps she woud have deprioritized her prized salty snack.)

The brother would have had no chance of lifting her had her growth not been stunted by illness. Undersized children are all too commonplace in a pediatric HIV clinic.The family-sized bag of corn will no doubt add some plump. A mouthful may even make the blood draw hurt less.


Friday, November 23, 2007

Jabu’s mother - A patient encounter


Jabu’s mother held the off-white white face cloth up to her eyes to hide her tears. Her husband died of AIDS and TB three days ago, and I had just told her that her HIV+ nine month old might have TB.

“Until we are sure that your daughter does not have TB, it is dangerous to start the ARVs,” I explained to her.

“But she needs ARVs,” the mom responded. She was absolutely right, and I told her this.

Jabu’s mother knew that if her husband had received ARVs earlier, she would not be a widow. She did not understand that starting ARVs in a child with an active TB infection is life-threatening.

Her mother-daughter family was now a family of two, and there is really no such thing as a family of one, so cutting corners was not an option. I explained this to the mother, and she understood.

Jabu’s mother supports her daughter by sewing in a clothing factory. She dressed the part, with an elegant pastel green blouse and flowing, floral-patterned black skirt. She wore a solemn, proud expression, even as she mourned the very recent loss of her husband. Every 15-20 seconds, she would move her small towel to her face to absorb tears and hide pain. She pressed the cloth firmly against her face with the index fingers of both hands.

Jabu is scheduled to get an x-ray tomorrow and come to clinic on Monday, after her father’s weekend funeral. If the film is clear, we will start ARVs that day. If it is not, she will receive TB treatment for 1-2 months and then start highly active antiretroviral therapy.

I reviewed this plan with the mother and gave her bus fare for the return trip to clinic, for funerals are expensive and running a sewing machine in Swaziland pays little, no matter how fashionable and valuable the product.

While it is not my practice to hand out money to patients, no mother should have to worry about how she is going to scrape together three and a half dollars while burying her husband.


Thursday, November 22, 2007

Why I love my job - Quote 18 of 20

Sisana, 60yo grandmother of 4yo Sindiswa: “My right arm hurts.”

Me: “Where does it hurt?”

Sisana: “Here.” She ran her hand over her right arm, slowly, from shoulder to wrist.

Me: “When does it hurt?”

Sisana: “When I plow the family fields.”


For most all Swazis, Swaziland is not an easy place to live. Without the courage and vitality of Swaziland’s grandmothers, hope would wear thin.

See also these previously posted narratives featuring this admirable group of women:
Ticklish - A patient encounter
Broth, no bread – A patient encounter
An old woman is looking for you – A patient encounter
Happy Mothers’ Day from Swaziland, with love


Wednesday, November 21, 2007

Uncertainty - A patient encounter

I picked up my first file of the day around 8am this morning.

The facesheet read, “URGENT. Child in ER.”

Our clinic “emergency room” is set up to stabilize the very sick before sending them to the hospital.

The hospital was exactly what the patient in the ER needed. She had lost 1.2 kg over the previous month, which unfortunately was nearly one fifth of her total weight. She was lying on her back on a stretcher in the middle of the room. She had scabs lining her lips.

Her father told us that, though eating was painful, she had been eating. This was certainly good news.

“But…,” the father continued, “She vomits everything.”

He pronounced the word everything slowly, emphasizing the word’s totality.


This explained the weight loss.

I looked at the child, and the child looked at me. Her crusted lips tensed and her eyebrows wrinkled a bit, then she began to make a soft, humming noise each time she exhaled. It resembled the monotonic whir of a laptop’s cooling fan, or the maybe the sound of a carpenter’s rotary power-saw a few houses down.

The girl was crying. Rather, she was trying to cry, but was too weak to do so convincingly. I do not know if she was asking for help or telling me to buzz off.

I knew that I could not do both.

We were unable to send the child to the hospital. The father refused. The reason for this was simple: there was nobody to stay with the child on the ward. (Because of staff shortages, admitted children without caregivers often receive inadequate inpatient care.)

We gave the child a shot of broad-spectrum antibiotics, some milk-based formula designed for severely malnourished children, and sent the child home. She is scheduled to return first thing in the morning.

I tell myself that we did not send the child home to die but, to be honest, I am not sure that the child will be back tomorrow.


Thursday, November 15, 2007

Swazi HIV Awareness Poster Series - (20 of 20)

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Wednesday, November 14, 2007

Why I love my job - Quote 17 of 20

"Hey! I am so happy."

- 32yo Mr. Sibandze when I told him that his CD4 had gone from 45 to 206 after a few months on ARVs.

I was also happy for Mr. Sibandze.


Tuesday, November 13, 2007

HIV is not an emergency, is it? - Recent media

In early October I promised to write about why HIV is quite literally an emergent disaster. I was planning on using notes that I took during a recent lecture by Derek von Wissell, the Director of NERCHA, the entity responsible for implementing Swaziland’s response to the HIV/AIDS. Dr. von Wissell is also a former Swaziland Minister of Health .

Well, a friend sent me a link yesterday (thanks Anna) where Dereck, under the pen name "Government of Swaziland", summarizes the talk, and while the article is accented by some doomy, gloomy prose, it is interesting.

Have a look: Reviewing 'emergencies' for Swaziland - Shifting the paradigm in a new era.

(See also my previous post titled "Parentless children with nothing to lose" which I wrote after a talk Dereck gave about the mushrooming orphan problem here in Swaziland.)

Monday, November 12, 2007

Why I love my job - Quote 16 of 20

"I am interested in doing everything that you say. I want my baby to be safe. I am here to get pills to protect my baby."

- 27 year-old Lydia during her first visit to the Baylor clinic here in Swaziland. She is HIV+ and 28 weeks pregnant.


The prevention of maternal to child transmission (PMTCT) of the HIV virus is cheap and really quite simple. Essentially all babies born to HIV+ mothers can potentially be born without the virus. While such prevention is the norm in the USA and Europe, PMTCT is the exception here Africa.

For want of a few pills, baby human beings are unnecessarily infected with a preventable and deadly disease on their way into the world, many before the first breath.

When I think about this, I do not feel proud. I feel embarrassed and ashamed.


Wednesday, November 07, 2007

Important numbers - A patient encounter


Mthobisi’s fleece sweatshirt had the number ‘14’ on it. I remember this value because it matched Mthobisi’s CD4 count on 31 January, 2007, just before he started ARVs.

Clothes with two digit numbers on them are popular these days. In addition to my patient’s #14, there was a #23, a #42, and a #00 in clinic yesterday.

While I have no problem with numbered apparel, I would prefer that the numbers have some significance. Perhaps they could even be accompanied by an explanation. Imagine, for example, a fleece sweatshit that says:

299, 792, 458 m/s – the speed of light
6.022 x 1023 – 'Avogadro’s constant', or the number of protons in a gram of pure protons
3.14159265 – 'pi', the circumference-to-diameter ratio for any circle in a plane
i – the 'imaginary unit', or the square root of -1.

As I am not a mathematician, I put together my own list of significant numbers, sticking to the more marketable, two-digit fashion:

01 – the number of dollars that 80% of Swazi’s survive on each day
33 – the healthy life expectancy of the Swazi male, in years
50 – the percentage of HIV+ children that die before their second birthday without treatment
02 – number of pills required each day to keep an HIV+ human being alive
44 – how many cents each of those pills costs, according to Clinton Foundation 2006 ARV price list

And my favorite number of all:

510 – Mthobisi’s CD4 count after 10 months of ARVs


As Mthobisi left the exam room, I held out my hand to shake his. He shook my hand firmly with his left hand, realized that he should have offered his right (as is the custom), and quickly corrected himself. He smiled as I complimented him on his strong handshakes.

As I typed up a summary of his visit, I wondered if I might some day read a story in the sports section of the paper about an ambidextrous athlete from Swaziland that pitched (or in the case of cricket, “bowled”) the perfect game. Or, even better, maybe there will some day be a "Mthobisi’s constant".

Five-year-old Mthobisi could grow up and destigmatize the virus he was born with, or perhaps even cure it.

Yes, the number 510 is a beautiful and important number.

It is the number of CD4 cells per uL of blood that is allowing Mthobisi to become whatever he is going to be when he grows up.


Tuesday, November 06, 2007

One hundred and one Swaziland destinations - #20: Durban’s tokolosh-slayer

My sidewalk purchases.

A few weeks ago, I traveled to a town near Durban to help give a week-long advanced pediatric HIV care and treatment training. The drive to Durban is just under 6 hours from Mbabane.

The following is one in a series of several Durban sites worth checking out.

The two medicinal potpourris pictured above were purchased from a traditional healer who dispensed from a sidewalk beneath an old rusty bridge near a congested marketplace in an out-of-the-way, allegedly “unsafe” part of Durban. (Come to think of it, maybe I should not wholly endorse this particular destination.)

The concoction near the top of the photo (the one that looks like woodchips), is for making tea. The ingredients, if mixed in cold water, are designed to bring the drinker good luck. According to the sidewalk healer, if mixed in hot water, the mixture is potentially deadly.

The other product, which looks like leftover, overcooked, de-skewered shish kebab, is meant to be scattered around ones property to protect against the Tokolosh. The Tokolosh is a mischevious spirit with origins in Zulu mythology. He is said to have only one arm and one leg, the face of an old man on a boy's body (and, for those interested in looking it up, other more explicit anatomical features). The venerable Tokolosh can become invisible by swallowing a pebble and he likes women, sour milk, and fighting. If you manage to fight him and win, however, he will teach you magic and the art of healing.

I think that is what the entrepreneur selling these off-beat, magical wares must have achieved prior to my arrival.

Monday, November 05, 2007

Pretty woman - A patient encounter

“What is your relationship to the child?” I asked.

She looked too young to be the mother of the school-aged child accompanying her. “I am his mother,” she replied.

I almost said “Wow. You look too young to be his mother,” but I paused. I have learned that appearing young is not necessarily considered desirable by many here in Swaziland, where the principle struggle is to stay healthy so that you can some day achieve oldness.

This mother was not old, but she was certainly healthy and therefore, I suppose, on track. She was also HIV positive.

She wore an elegant headscarf and petite earrings. Her beige, delicate dress was simple but pretty, her posture correct and effortless, her face stately. “This woman should be sipping mint juleps watching a contest between hundred-thousand dollar horses," I remember thinking, though I admit that it was a strange thought as I know little about Kentucky racehorses, much less their market value. I did have a minty whiskey drink once some years ago.

Of course, this lady had not left home before dawn for lowballs or airy leisure. She had put on her best dress, walked to the main road and hailed a minibus in the dark because she is an HIV+ mother living in a Kingdom where four of five live on less than a dollar a day, the king has umpteen wives, and four of ten mothers are HIV infected. She had left the house for one simple purpose: to procure medicines that will keep her son alive.

Samkelo sat comfortably next to his mother on one of the clinic’s rigid plastic chairs. His face was tranquil, his expression dreamy. The child’s left arm was hanging casually over the chair’s backrest. He seemed to know that, on the other side of the exam room window behind him, it was another beautiful spring day in Swaziland. He and his mom had arrived at six in the morning, and he knew that he would not be indoors for long.

If the waiting room had not been so full, perhaps I would have been similarly wistful.

I asked his mother if she had told Samkelo why he comes to the Baylor clinic. She had not. Because he was almost nine years old, I suggested that she sit and talk with him about it soon. “If you would like, we can discuss it with him together when you come back to clinic in two weeks,” I added.

She looked over at Samkelo, the way a mother looks at a child when she wants to protect him. She said she would think about it. Samkelo, with a backdrop of soft yellow light and a swaying avocado tree, looked back and smiled at his mom, the way a child smiles at a mother when he knows she will protect him, even against those things he does not yet understand...or at least try.

The branches of the avodaco tree were heavy, some branches supporting four or five of the "pears" (as they are refered to locally). As Samkelo stood to leave, I imagined how much fun it would be to climb the tree with him and give him a lesson on how to make avocado pears into guacamole.

We would insist that his youthful mother relax on a blanket in the shade and we would serve it to her in an impeccable dish which we would have left in the clinic freezer for a few minutes so that it was slightly chilled.


Thursday, November 01, 2007

My family eating shrimp po'boys in the town where I was born: Today's [belated] travel digest (5 of 10)

From left to right: Chuck (dad), Ryan (me), Sarah (younger sister), Alan (brother-in-law), Nick (younger brother), Victoria (Nick's girlfriend), Jeannine (mom)

I did not post as much while in Texas as I had planned. (The Phelps homestead is a busy place.)
I will try to supplement the previous home grown Texas posts from here in Swaziland.

So, here is a photo of my nuclear family, plus partners. (Not the "howdy partner", squinty-eyed, spittoon-dinging, six-shooter-slinging, bowed-legs-at the-knee-from-too-much-saddle-time kind. The other kind.)
We are in Galveston, Texas a couple days prior to my return to Africa.