Pediatrician in Swaziland

Raising the bar - A numerical snapshot of Swaziland's HIV epidemic

2009-02-01T11:22:00.004+02:00

www.empoweranother.org

I recently rediscovered a pdf document with an excellent statistical overview of Swaziland's HIV epidemic, compiled by UNAIDS and presented last year in Mozambique. (See link.) The Swazi-specific slides begin on page 13.

Welcome!

2009-01-31T01:00:00.000+02:00

If you are a first-time visitor to this site, please note that there are several labels that help categorize my entries over the past year so that you can pick out what you are most interested in. If unsure where to start, the pediatric HIV "Patient encounter" narratives are a good place.

I actually currently reside in Botswana, and have begun to post more on my Botswana site, if you'd like to hop over (http://www.pediatrician-in-botswana.blogspot.com/). Cheers.
-Ryan

One hundred and one Swaziland destinations - #26: "Swazi Candles"

2008-12-07T18:19:00.006+02:00

A Swazi candle-maker (www.mccullagh.org)

Swaziland is historically a cattle-based society, and fresh bread is considered a delicacy. Butchers are bakers therefore abound. But what of candle-stick makers?

I have written before (Swaziland destination #16, I believe) about the Ngwenya glass factory, where broken shards are melted into molten lava and then, with a spin of a pole and a few flicks of a spatula, become transparent elephants, rhinos, lions, giraffes and other forms...including fancy wine glasses.

Swazi Candles is the waxen version of the glass factory, and we are not merely talking about wax sticks. There are few animals in the Kingdom (the Animal Kingdom, that is) that do not have some representation in the showroom. For the classicist, there are some stick designs, but these are carefully patterned or pied so that one does not mistake them for ordinary candles.

I have attached several examples below. See http://www.swazicandles.com/ for more information.

www.holidaycheck.de

www.papaafrica.fi

www.mccullagh.org

johannesburg.hotelguide.co.za

The king, the pawns, the same unfortunate box - Recent media

2008-12-07T18:07:00.006+02:00

In a recent article in The Economist magazine titled, It’s Good to be King, the author asks why Zimbabwean leadership is being condemned worldwide while the Swazi king et al have escaped similar scrutiny. According to the article, Swaziland, the current rotating chair of the body dealing with peace and security for the Southern African Development Community (SADC), has banned political parties since 1973, while the Swazi king recently placed the opposition leader behind bars.

As readers of this blog (as well as Economist readers) know, Swaziland is hungry and poor. It leads the world in HIV prevalence (Botswana, where I currently live, is a close second). Though this blog for the most part avoids direct, bare-knuckle political commentary, the article linked above does not. It suggests that Swaziland’s leadership, beyond that demonstrated by HIV prevalence, is poor, and that the countries ailments are continually perpetuating by (and I am paraphrasing here) a monarchical milieu of polygamy, decadent royal spending, and, on substantial matters of governance and public health, careless inaction.

Here is the link again, in case you missed it.

2008-11-06T11:44:00.000+02:00

Yesterday, I found myself staring blankly at the above color-coded map of global HIV prevalences. Below the map there was a list several numbers, the kind of number with many trailing zeroes. As I looked at the map, I got that feeling that I sometimes get when looking into the night’s sky--that feeling of being very very small.

Monty Python has a mirthful song called “The Universe Song,” and its middle verse goes like this:

"Our galaxy itself contains a hundred billion stars,it's a hundred thousand lightyears side to side.

It bulges in the middle, sixteen thousand lightyears thick,but out by us it's just three thousand lightyears wide.

We're thirty thousand lightyears from galactic central point,we go 'round every two hundred million years.

And our galaxy is only one of millions of billions,in this amazing and expanding universe."

The song is light-hearted and I sometimes listen to it for find it comforting. There is comfort to be found, I believe, in the idea that we are insignificant, no matter what we do or do not do. The acknowledgement that life is uncontrollable, that we are to an extent along for the ride, is, in a sense, a relief.

Well, for me, maps with a lot of reds and zeroes that represent sick children have a similar effect. They remind me that I am just a pixel on the map. (As I was born in the USA and born without HIV, I suppose I am one of the burnt orange pixels in the map above.)

Yesterday, in Botswana where I currently live, I saw a twelve year-old child with recently-diagnosed HIV and undiagnosed tuberculosis. His name was Samuel. He had been coughing and losing weight for months, and had several fevers a day. I asked him how is cough was, expecting him to say “better,” “worse,” or “the same”. Perhaps “wet” or “dry”. Instead, he said something that I did not expect. He said, “It hurts.”

Because of a 0.0001mm germ, Steve’s immune system was in tatters. For those of you who know the pleasure of picking out the Milky Way on a dark, out-of-town night, you would have had no problem recognizing the stippled white smudges over the upper lungs of Samuel’s grossly abnormal chest x-ray.

Samuel was sick, a dark red pixel on the map of global HIV, in danger of flickering out of the picture all together.

Having told you this, the question I want to ask you is as follows: On a small planet in an immense galaxy that is hurdling through space with countless others, on a planet where millions are dying of a tiny virus, does it matter if I help Samuel get better?

Or perhaps, my question for you is this: Is there anything in the big big universe that matters more?

--

The HIV virus. (www.images.google.com)

"A Sunday Afternoon on the Island of La Grande Jatte", by Georges Seurat's, uses Pointillist technique (which I have always called “stippling”) to capture the scene at a nice seaside park. I learned about this painting as a child, and then saw it again in the 1986 film Ferris Bueller's Day Off. In this film, Cameron stands very close to the painting and zooms in on the little girl in the middle, only to find that there is no shape or form to her face. Personally, if I ever have the chance, I am going to do the same with woman carrying a parasol in the right foreground of the painting. Though you may not be able to see in the image above, she seems to wear a subtle smile. I like to think that, if I stood inches from the original painting, there would be but one or two dots that ensure that her expression is one of contentment and not one of indifference or sadness.

One hundred and one Swaziland destinations - #25 Nhlangano

2008-08-10T17:46:00.003+02:00

www.upload.wikimedia.org

There are the well-served, the underserved and there are the unserved (the good, bad, and ugly, if you will).

Two and a half years ago, HIV positive children in Swaziland were crowded on the ugly end of this spectrum. Since Baylor’s arrival, these children have been shifting slowly. A recent email from a colleague, Dan Dewey, gives an interesting snapshot of his first experienes at Swaziland's Nlangano Health Centre as he witnessed (and catalyzed) this transition.

He wrote:
"On my frst day of outreach clinic, there were two children there. Now, a few months later, [the clinic] is overflowing. Some days half of the children have TB. Many are malnourished and most are not yet on treatment. There is still bad rumor around Nhlangano that nothing can be done for HIV positive children prior to 18 months of age, except maybe treating opportunistic infections. The health center is overwhelmed with sick people, HIV exposed babies, etc. There is a lot of need.”

When it comes to health services, the good, bad and ugly might be thought of as “needs met”, “we are getting there”, and “needs ignored.” Well, thanks to Dr Dan Dewey and Baylor, things are becoming less ugly for the HIV (and TB) infected children of Nlangano.

We are getting there. We must get there.

PS: If you have never been to Nhlangano (chances ar you haven't), check out this amateur video. It demonstrates that we are not talking about a desert, bush, or jungle. This is a town, a town without adequate medical care for the thousands of sick children in its catchment area.

YouTube - Nhlangano, Swaziland

One hundred and one Swaziland destinations - #24: "Gone Rural"

2008-04-27T19:05:00.003+02:00

http://www.goneruralswazi.com/

Based on a microenterprise empowerment model, this non-profit, shop-based collection of Swazi handicrafts is a popular destination for gift-seekers. While all souvenirs bought in Swaziland will no doubt support someone in need, this project does so deliberately. Their prices are not the lowest, but their quality is high. They have some of the nicest local products I have seen here, especially those that derive from reeds.

Well, I should say that “reed” is not the correct word for the long, rigid grass used to make these products. It is a type of tall grass, and there are several versions that grow wild here in Swaziland. After an extensive discussion with the staff at the coffee shop from where I write, they wrote down three Swazi words that have no clear English translation but represent the three primary types of reeds/grass that is used to make these decorative souvenirs. (lukhwane, ncoboza, lukindzi)

The inventory at Gone Rural is both from pragmatic and artistic. The craftsmanship that turns wild reed-grass into art (the collecting, dyeing, weaving, tieing, etc) is impressive. These are more than handicrafts. They are a population's livelihood (>700 ruralwomen contribute to the inventory).

The origins and the product are simple. The struggle it represents is anything but.

One hundred and one Swaziland destinations - #23: "House on Fire"

2008-04-13T16:50:00.004+02:00

The back door to HoF...as seen from Melandelas Restaurant when the sun is up.

Think eclectic soapstone architecture and good music surrounded by cane fields. That is House on Fire. After dark on a weekend (way after dark usually), it might best be described as a hippy Disneyland (drug-free, of course). Open pit fires, a diverse crowd, a full bar, a tiered dance floor, and some of South Africa’s best DJs and bands. "HoF" is by far the heaviest hitter in Swazi nightlife. For last year's Bushfire festival (will post related pics soon), an outdoor stage was built, and in the upcoming months alone Freshly Ground and Johnny Kleg (two of South Africa's finest) are playing.

The venue is located in Malkerns, <30 href="http://www.house-on-fire.com/">www.house-on-fire.com/)

HoF's 'stonework', up close.

The view from the back lawn of HoF, by day. Also beautiful at night.

A traditional Swazi hut, behind HoF, near Melandelas.

One hundred and one Swaziland destinations...revisited

2008-04-04T13:07:00.002+02:00

A friend of mine from pediatrics residency, Dr. Dan Vostrejs, is hoping to move to Swaziland soon. He recently told me that my blog was a handy reference as he tailored his pre-arrival expectations. His comment made me realize how neglectful I have been in meeting my goal of "101 Swaziland destination" posts.

While this is not a tourist site (most of my posts relate to my clinical and cultural experiences here), I receive a few emails a month from readers planning a trip to Swaz, and I always find myself typing out the same list of recommended activities. Well, in the upcoming weeks, as I get re-settled in Botswana (and begin to blog from there), I am not only going to grow (perhaps even complete) my list of 101 Swazi destinations, but I am going to try and rank them in some useful way.

Swaziland, after all, is small, with plenty of low-hanging tourist fruit both within its borders and nearby, but there are few practical guides for those seeking them out. So, check out the Swaziland destinations label and, as always, stay tuned for more.

Ryan's list of useful HIV websites

2008-03-23T02:10:00.003+02:00

It just occurred to me that it might be a good idea to put together a list of HIV websites that I have found useful while working in Africa. This is by no means a comprehensive list. Let me know if I have left good ones out.

Baylor International Pediatric AIDS Initiative (BIPAI) website/
Contains links to complete our HIV Curriculum for the Health Professional, our Pediatric HIV Pictoral Atlas and other Educational Resources.

ICAP News and Resources links International Center for AIDS Care and Treatment Programs (ICAP) summarizes recent press releases and media coverage. http://www.columbia-icap.org/resources/ is even better (the "pediatric resources" link is rich with excellent references and tools). Thanks Floriza!

ITECH Clinical Training Materials Database
Great for putting trainings together. They post tools from several orgs that are pretty easy to search.

HIV Insite
Comprehensive, up-to-date information on HIV/AIDS treatment, prevention, and policy from the University of California San Francisco. They also have a page with links to recent HIV-related national and int’l guidelines.

Kaiser Daily HIV/AIDS Report
An excellent daily HIV/AIDS news summary from the Kaiser Famliy Foundation.

Medical News Today
A good summary of HIV/AIDS-related news, borrowing heavily from the Kaiser Daily Report above.

Elizabeth Glaser Pediatric AIDS Foundation Newsroom
Summary of recent news.

Clinton Foundation Media Center
Another source for summaries of HIV news.

International AIDS Alliance Publication Search Page
Allows searching for country-specific or topic-specific information.

www.aidsmap.com
General info links to the following: news, treatment & care, hiv worldwide, living with hiv, preventing hiv, organisations, hiv basics and more.

What am I up to? (January-March, 2008)

2008-03-21T18:26:00.002+02:00

Yours most truly, in my BIPAI office in Houston, Texas.

For the past two and a half months, I have been living and working in Houston at BIPAI headquarters. My office is on the 12h floor of the dapper Baylor-affiliated Texas Children’s Hospital.

For those new to this site, BIPAI stands for “Baylor International Pediatric AIDS Initiative” and it is this Initiative’s objective to keep the HIV-uninfected uninfected and to keep the HIV-infected alive. For about a year and a half (from August, 2006 to December 2007 that is), I lived in Swaziland and took on that objective. I did this as one of several dozen Pediatric AIDS Corps physicians throughout the sub-continent.

The job was spectacular. Spend a few minutes looking over this blog and you will get an idea of just how much I loved it. Yes, there were frustrations. Many of these related to my wishing that I could do and be more for that troubled Kingdom’s children. My efforts seemed too too little, and I was reminded daily how itty bitty Ryan Phelps was in the face of a devastating global epidemic. That was by far the most frustrating aspect of the job.

That, however, is not why I am currently at BIPAI headquarters. There are several reasons (I am a 'Texan' after all), but I never equated being but one person with being insignificant. On the contrary. Hundreds of children (perhaps more) who would be dead are alive, and I played a part in their survival. Granted, I played a small part, but we are talking about children. Helping but one is big. Very big.

I continue to play my role here in Houston, where I am helping to cover the Baylor Retrovirology Section’s clinical services, among other things. The time has been rich and perspective-lending. I plan to share more about my time here in Houston (and those new perspectives) in the weeks ahead, even as I head back to Africa.

In early April, Botswana will become my home, and from there I will continue to share stories as long as stories come my way and time allows.

I am about to check the availabiliy of the website "Pediatrician in Botswana"... or maybe "Pediatrician in Africa"?

Please do stay tuned.

2008-03-19T19:13:00.000+02:00

Scabies in an immunocompromised baby.

There is an interesting article in this week’s New York Times, titled “The Price of Beauty: For Top Medical Students, an Attractive Field .

Yesterday, I think, was the day when medical students here in the USA matched into residency positions for specialty training.

The article summarizes the efforts of two Harvard medical students to match in a dermatology residency. It outlines their background, the reasons for their wanting to enter the field, etc.

The article points out that of late an increasing number of the medical students with the highest scores and honors are becoming dermatologists and plastic surgeons. One excerpt reads, “The vogue for such specialties is part of a migration of a top tier of American medical students from branches of health care that manage major diseases toward specialties that improve the lives of patients…”,

Of course, most all disease is major when examined from the perspective of the diseased, and life improvement is undeniably good. Surviving and surviving well is and will forever remain a most worthy goal, and helping others do so a most worthy cause.

It follows that dermatology, like all fields in medicine, offers real opportunity to help sick people and is therefore a great line of work.

In the article, one of the soon-to-be dermatologists was not so eager to generalize “The No. 1 thing that is going to save your life is the humdrum preventative stuff like blood pressure and cholesterol,” he said, “But there is not a lot of respect for doctors who do that because anyone can get into it. But if you are an expert where no one else is, like the eye or the skin, your input is valued.

Hmmm.

“Humdrum preventative stuff”? What an unfortunate quote. Is dermatology somehow less preventative (cancer?) or repetitious (acne?) than general medicine? I never thought so.

The idea that “there is not a lot of respect for doctors who do [the stuff]” makes me wince. Is not every cure necessitated by a missed opportunity at prevention? Personally, I prefer low cholesterol to bypass surgery.

As for the assertion that, “Anyone can get into [the stuff]”, I would point out that there are several kind, smart folks in the world that want to be doctors but cannot.

Until recently, I worked as a pediatric HIV doctor in Swaziland. There are many “major diseases” there. There is no medical school in the country, and, before 2006, there was not one public sector pediatrician. To put it simply, Swazi children suffer and die all the time for lack of access to medical doctors and medical care.

Their travails do not stop there. Swazi children have little or no access to public schooling, and most children of the Swazi countryside will never learn to read. Medical school, I would say, is quite out of the question.

I wish this were not true, because there are entirely too few doctors (of any specialty) in Africa. Almost all of the health care professionals working there are undertrained, underpaid, and overworked. They fight hard and their patients die anyway so they often burn out early and sometimes, by no fault of their own, find it more and more difficult to care.

The organization with which I work—the Baylor International Pediatric AIDS Initiative—is doing its part to help address this workforce crisis. BIPAI is placing doctors on the ground and is heavily invested in training health professionals around Africa Wherever possible, BIPAI focuses on task shifting. In other words, it is part of my job to help ensure that general nurses and other health professionals learn to do as much of what I do as possible. Pediatric HIV care, while complicated, does not require an MD. I can only hope that some day I will wake up to find my skills commonplace and my role in Africa obsolete. This would mean healthier kids.

Unfortunately, the day when I am to wake up and find myself not needed is far away.

In any case, I am proud that it is my job to help prevent and (if unable to prevent) treat all-too-common illnesses. I am equally proud to help others learn and take over my job.

I am not quoting the medical student in the NYT story to pick on him. I am certain that he is well-meaning. I do not blame him for seeking respect, for it goes without saying that everyone seeks a modicum of some third party’s esteem. Even respect for respect’s sake is no doubt an attractive indulgence. (As is money.)

I just wanted to point out two things that I think all aspiring doctors should know:

(1) Remuneration and perceptions of prestige aside, every job has an element of the humdrum. One must find something that he or she can do ten thousand times and still find meaningful.

(2) Not everybody gets to be a doctor…or a nurse…or a public health specialist…or a community health worker. For those that do, the health profession is a unique and monumental opportunity.

So, as long as my blood pressure and cholesterol allow my heart to keep beating and my skin protects me from the elements, I will do my best not to thwart this opportunity.

Despite the tone and questionable content of the article, I hope that the brightest American medical students will do the same.

Swaziland in pictures

2008-03-19T04:12:00.000+02:00

I really enjoyed this short photo collection posted by a previous Peace Corps volunteer in Swaziland. See link below.

Kingdom of Swaziland, in pictures

If you are planning a visit to Swaziland, read this

2008-01-07T02:59:00.000+02:00

One of Swaziland's tens of thousands of orphans. (www.anamericaninpretoria.blogspot.com)

I reread the Swaziland National Vulnerability Assessment today, and was struck by how nicely it summarizes several of Swaziland's challenges. Have a look.

Stories about Sipho - A guest-blog patient encounter, continued

2008-01-04T04:14:00.000+02:00

I just noticed that the (BLOG) RED posted parts 3 and 4 of a patient narrative that I wrote a few weeks back.

Have a look:
(BLOG) RED: Stories about Sipho, Part 3
(BLOG) RED: Stories about Sipho, Part 4

And if you want to start from chapter one:
(BLOG) RED: Stories about Sipho, Part 1
(BLOG) RED: Stories about Sipho, Part 2

Happy 2008.

2008-01-01T00:56:00.000+02:00

Swazi children.

May we make the most of it.

Where have all the Swazi's gone? - Recent media

2007-12-30T00:35:00.000+02:00

"Where have all the Swazi's gone?" is the title of a recent article from Toronto's Globe and Mail, which discusses Swaziland's recent census results. According to the census, Swaziland has 300,000 fewer people than predicted by pre-HIV growth rates.

The article goes on to describe the "toxic mix" of factors that has fueled the country's HIV epidemic. Examples of such factors are:
- a culture that "condones, even encourages" promiscuity and polygamy among men
- a culture that denies women the right to negotiate condom use
- a "limited economy" that relies on sending men to work in South Africa for long periods of time
- a king with several wives who has denied the magnitude of the problem
- the country's understaffed and underfunded health system

The result: Swaziland is shrinking, and 26% of adults and 49% of young women between the ages of 25 and 29 are HIV positive.

Season's Greetings

2007-12-25T15:30:00.000+02:00

There are many 'things' to be mindful of this season as we give our gifts and make our resolutions. Click here for some examples.

See the following post for others.

For those children not nestled all snug in their beds

2007-12-21T17:22:00.000+02:00

Siphelele, on Young Heroes waiting list

I rarely solicit on this website. When I do, it is for Young Heroes, an organization that provides direct assistance to orphans in Swaziland. For example, you can sponsor Siphelele, above, who is six years old and not currently in school. See the website for photos of other unsponsored children.

Please consider sponsoring a child as a holiday gift. 100% of your donation goes to the family in need. Zero % goes to admin. Yes, zero.

I have posted links to my previous entries on this worthy organization below.

Parentless children with nothing to lose
Ryan's birthday wish
An offer of solace and hope

Drawn - A anonymous Swazi child

2007-12-20T17:50:00.000+02:00

Sipho (pictured standing below) walked into the clinic office where I was working a few weeks back and told me he had something to show me. He took me down to the first floor where two carbon pencil sketches had recently been hanged. The girl looked familiar, and he confirmed that I had taken the original photos (also attached below) on my way back from St Phillips. The girl (of about 4 years old) was carrying a bucket of water down a long dirt road in rural Swaziland, and this made an impression on me. Sipho, the artist, was similarly taken by the child, and drew her. A very nice job, Sipho.

Sipho and his two sketches.

Anonymous Swazi child.

Anonymous Swazi child 2.

Have difficult-to-shop-for-relatives? Here is a humane gift idea: support a Swazi orphan

2007-12-17T15:16:00.000+02:00

This misspelled poster, created by rural community health workers at a recent Baylor-sponsored pediatric HIV training, made an impact on me.

I wish that 'human' and 'humane' had similar meanings, but they do not...at least not here in Swaziland.

Swaziland has the world's highest rate of HIV infection. The disease is filling local cemeteries and creating a generation of orphans, nearly 70,000 of them. The small kingdom has ~15,000 child-headed households.

As regular readers of this blog know, I have found great meaning in helping restore dignity to the lives of some of these children. My role is small, but I believe in it.

As you plan for the upcoming season of giving, you can play a role too.

Please check out the following links for to learn how to support local Swazi children orphaned by HIV:
www.youngheroes.org.sz/
Parentless children with nothing to lose (previous blog entry)
Ryan's birthday wish (previous blog entry)

Tacos in Swaziland - Cultural encounter series (4 of 10)

2007-12-13T15:11:00.000+02:00

Treasure, Anne, an Mlingisi eating their first taco.

There are no tacos in Swaziland. There are no Taco Bells, Taco Buenos, Taco Cabanas, or for that matter any taquerias, taco stands, taco trucks or taco shacks named Taco Something.

There is a place downtown named Pablos with a desert cactus on the sign, but they serve burgers.

Well, I recently found taco shells at the local grocery store. I do not know if there was a supply chain routing error or if I just got lucky, but there they were. I believed they were "El Paso" brand.

I made that tacos that night for dinner, so many in fact that I had seven extra, which I brought to work the following day. I sat down in the kitchen to enjoy one, and handed out the others to the next six Swazi colleagues that happened to drop by the kitchen.

None of them had ever heard of a taco or seen anything like it.

Here were some of their comments:
"Oooh. It is sooo nice."
"So, doc, is this really what they eat in Texas?"
"What is it again? A teekos?"
"How do I do it? Do I hold it like this?"
"You really have to share the recipe."
"I like Mex-Tex. I must visit some time."
"Oh! It tastes just like Doritos."

Senzo and the doll - A patient encounter

2007-12-11T16:09:00.000+02:00

Dolls in Exam Room 8

Senzo was pretending to breastfeed a doll when I walked in the exam room. He sat beside his mother and infant sister, holding the head of the stuffed toy firmly to his tummy. Occasionally, he would tug at his jacket to try to move it out of the hungry doll’s way.

He looked up at me gave me one of those hey-look-at-me-look-what-I-am-doing looks.

“Aren’t you going to be a good big brother!” I dutifully told him in response. He did not understand a single word of English, but his smile suggested that he understood the sentiment.

Senzo wore rainbow-patterned flipflops, baggy corduroy pants, and a grey and maroon sweatshirt. He was small but bouncy.

When I examined him, he seemed no less excited than if I had been passing out candy dressed up as Disney’s Mickey Mouse. He watched every move with amazement.

Watching the child watch me, I too felt amazed. Senzo was one of Baylor’s many success stories here in Swaziland. When Senzo was a year old, his CD4 was below 500. Now, thanks to a few pills and careful follow-up, his count is nearly four times that, well within the normal range.
After refilling Senzo’s ARVs, I turned to his mom. "Are you going to get Senzo’s little sister tested?" I asked.

“Yes. Next time I am at the clinic,” the mom replied.

“Good. If the baby tests positive, we will take very good care of her, just like we have taken very good care of Senzo.”

One hundred and one Swaziland destinations - #22: "The Swazi cultural village"

2007-12-06T13:47:00.000+02:00

I recently took a trip to the Swazi Cultural Village about twenty minutes east of Mbabane, where one can tour a traditional Swazi village and see dancing. Swazi dance is similar to Zulu dance, with singing, drumming, whistling, alternating kicks, stomping, and plenty more. A true feast for the senses.

The link below will take you to a very short video clip. (The Swazi internet connection encourages brevity.)

Swaziland cultural dance

One hundred and one Swaziland destinations - #21 The weaver birds

2007-12-05T13:02:00.000+02:00

chandra.as.utexas.edu

The weaver birds are back in Swaziland after a wintertime hiatus. So are their pendulous, seemlingly precarious abodes.

See this YouTube video for some brief video footage of their nests, and see the two links below for my previous weaver-bird-inspired entries:
A brief encounter with a weaver bird
So, here I am - An introduction

Why I love my job - Quote 20 of 20

2007-11-27T16:13:00.000+02:00

“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.

Why I love my job - Quote 19 of 20

2007-11-26T14:55:00.000+02:00

“Buya.”

“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.

Jabu’s mother - A patient encounter

2007-11-23T14:49:00.000+02:00

www.stjoan.com

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.

Why I love my job - Quote 18 of 20

2007-11-22T09:35:00.000+02:00

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

Uncertainty - A patient encounter

2007-11-21T16:07:00.003+02:00

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.

“Eev-err-eee-thing.”

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.

Swazi HIV Awareness Poster Series - (20 of 20)

2007-11-15T16:56:00.000+02:00

Why I love my job - Quote 17 of 20

2007-11-14T14:14:00.000+02:00

"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.

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

2007-11-13T12:28:00.001+02:00

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.)

Why I love my job - Quote 16 of 20

2007-11-12T12:18:00.000+02:00

"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.

Important numbers - A patient encounter

2007-11-07T16:52:00.001+02:00

(http://unihedron.com)

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.

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

2007-11-06T14:12:00.000+02:00

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.

Pretty woman - A patient encounter

2007-11-05T14:52:00.000+02:00

“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.

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

2007-11-01T15:46:00.000+02:00

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.

Training trainers in Swaziland

2007-10-29T19:41:00.000+02:00

This week, we are training a group of fourteen excellent nurses. We are teaching them teach others about pediatric HIV. The curriculum is based loosely on the South African advanced training from earlier this month. The group was recruited because they demonstrated advanced knowledge and leadership during our basic trainings, and so trainers-in-training are teaching us trainers-of-trainers plenty.

Here are a couple of photos. I will try to post more later in the week.

Bongile giving a talk on how to teach children about HIV.

A map of Swaziland. Post-it notes represent where trainers are currently working.

Yesterday's jog past the graveyard - Cultural encounter series (3 of 10)

2007-10-28T19:52:00.000+02:00

We had biked past the graveyard before. The first time I pedaled by the place, just less than a year ago, I did not know that dead bodies were buried there. It looked more like a quarry of some sort, or an unlikely rock garden. I say “unlikely” because I have yet to see a rock garden in Swaziland, and if there was a lonely gardener of stones, he or she would be unlikely to choose this exposed, treeless, featureless, eroding square of land.

Not the best place to bury something either, I suppose.

I did not point this out to the three men with shovels. On my next pass, a week later, they were methodically lunging toward an enlarging hole in the ground, moving earth and aerosolizing dust. Their shovels made the sound that cats make when frightened. Sometimes, when the tool’s metal hit rock, it made a different sound. A short-lived, lifeless one.

In the foreground, there was a prone, human-shaped shadow in the back of a carelessly-parked pickup truck. The able-bodied figure was awkwardly positioned and perfectly still. I did not stare, for the scene was already rife with indecency.

--

Yesterday, I jogged past the same cemetery. There were no grave-diggers there, or anybody for that matter. On the surrounding hillside, however, it was a busy Friday afternoon.

A few paces from the piles of dirt and rock, there was a child carrying a child. They were the same child, it seemed, but one was smaller. I believe they were sisters. They were at the base of the hill, walking up. Others followed, many of them students returning from the school in the valley below.

Further along, two men peered into the rusty bowels of an old tractor. One was crouched down looking up, while the other was perched on a tire, peering down. They both looked perplexed, as if there was no good reason for the ancient machine to be giving them so much trouble.

Ahead, two sheppard boys began waving their whips at a small herd of cattle that were slowly crossing the road ahead of me. Under the threat of the leather lash, the cows’ pace quickened. A calf, trapped between me and a hillside drainage ditch, leaped away from me in desperation. Despite the well-known nursery rhyme, cows are not able jumpers, especially on concrete. Shortly after a frantic extension of the front legs, there was slip, a buckling, and an awkward tumble. The calf regained its footing, seemingly satisfied with itself for having avoided both the runner and the whip.

As I began the two-kilometer climb to the top of the hill where I was to turn around, a child began to run alongside me. He was punching the air in front of him, like a shadow boxer, or, for those familiar, one of those miniature boxing nun novelty toys. I had no idea why he was doing this, nor did I understand why he was nudging me to the right side of the road. After a few seconds of fist-pumping and nudging, a four-wheeled cart sped by in the other direction. The child driving was holding a horizontal stick, like a water-skiing tow-rope. He was steering the vehicle with the same back-and-forth hand motions as my new running escort.

After the cart had passed, my gesturing protector smiled and asked me, “Want to ride it?” I answered “no thank you”, for it looked a lot like one of those old wood-and-red-metal Citizen Kane “Rosebud” sleds, and I crashed too many times as a child. (We rarely got more than an inch of snow in Texas, and this provides little cushion.)

I ran up the hill and turned back. I passed the graveyard. This time it was on the left. I crossed a bridge where a woman was washing her clothes in a shallow, smoky river. The water smelled of algae and sulfur. Five children shouted and waved from outside a shack built from corrugated tin and weathered wood. Their bubbly excitement when I waved back and said “hhheeeellllooo” made me feel happy but small, maybe even a little bit old.

I looked back at the hill I had just climbed. The rains have recently arrived to Swaziland, and the grass was rich and green, the color of a plastic turtle.

The graveyard was not green. It was brown and ruddy, the color of a place where too many young people are buried.

The children were still waving, so I shouted “Bye byeeee!”

Recognizing another of the few English words they knew, they were delighted, and each of them squealed the same word back several times.

Swazi HIV Awareness Poster Series - (19 of 20)

2007-10-25T17:31:00.000+02:00

Swazi HIV Awareness Poster Series (17-18 of 20)

2007-10-23T20:32:00.000+02:00

Swazi HIV Awareness Poster Series (14-16 of 20)

2007-10-19T18:13:00.000+02:00

Where I used to fish for bass - Today's travel digest (4 of 10)

2007-10-19T17:32:00.000+02:00

Phelps Lake.

This small lake (some might call it a large pond, but they would be wrong) is across the street from my childhood home. It is called "Phelps Lake", and is being guarded in the above picture by one of the household's new puppies.

Why pleasantries are so named - Today's travel digest (3 of 10)

2007-10-17T21:13:00.001+02:00

Prologue: For those new to the site, I am currently in Texas to take my pediatric credentialing exam and visit family. Therefore, the following dialogue occurred a few clicks west of Swaziland, in a north Texas coffee house.

“Good morning!”

The eyes of the greeted met mine, wearing what is most accurately described as a blank stare.

“Good morning,” I repeated, beginning to wonder if it was actually a good morning...maybe it wasn’t. It seemed like one, but I have told that I do err on occasion.

“Uh, good morning?” countered the young lady behind the coffee counter.

She didn’t know either.

“How are you?

The stare was replaced by that forehead wrinkle and flickering twitch of the eyelids that means “I do not understand you and I am suspicious that you might want to harm me.”

I gave up.

“A medium coffee, please.”

“You mean a grande?”

“Is a grande a medium?” (Everyone knows darn well that “grande”, literally translated, means “large.”)

“Yes.”

“Then, yes, I would love a grande,” I said in clarification, wondering if a “medio” was a small.

“That’ll be two dollars thirty-six.”

--

When it comes to greetings, Swazis have it right. In Swaziland, money does not exchange hands until the payer and payee greet one another. Favors are not asked until the there is a mutual well-wish. With very rare exception, niceties precede necessities.

Take this common Swazi exchange, for example: “Good morning. Good morning. How are you? I am fine. How are you? I am also fine, thank you. Good. May I have a medium coffee, please?”...and so on.

Only takes a few seconds, and I must point out that a cup of coffee, while nice in and of itself, tastes even better after some humanizing behavior.

Size inflation is no substitute for a smile.

--

(“Size inflation,” however, is worth its own blog entry. Stay tuned.)

The selfish [and possibly a wee bit lazy] gene - Today's travel digest (2 of 10)

2007-10-12T16:50:00.000+02:00

(www.dkimages.com)

Not too long ago, “people movers” were called “feet”. Though many other mammals scurry about on four, Darwin, Dawkins, Mendel, the double helix and the gang voted unanimously that a pair is enough, provided it is accompanied by some modicum of wit.

Well, several witty bipeds apparently got together and decided that the few hundred meters from the Atlanta airport’s international arrival gate to customs was too far for two feet, and they created a moving sidewalk. It transports those standing on it at ~3mph, about the speed of a Sunday stroll.

A moving sidewalk. (commons.wikimedia.org)

At the end of the airport's moving sidewalk there they engineered an escalator, a device that preceded "moving sidewalks" and “people movers” by several years. (Climbing stairs, after all, requires more exertion than walking.) The interesting thing about these particular pre-airport-customs escalators was this: There were no accompanying stairs.

My only option for getting from level one to level two was to plant my two feet on the motorized metal platform and wait. (Strange that escalator actually means "one that increases intensity.")

Near the top of the escalator, I ensured that my shoe laces were free so that I would not get sucked into the metallic bowels of the device. After my safe dismount, I noted that there was no nearby moving sidewalk, so I walked to the adjacent men’s room on my own. With alternating feet, I approached the sink to wash my face. When I arrived, I found a faucet without a handle, a soap squirter without a button, and paper towel dispenser without a lever. To my astonishment, thanks to motion detectors, I was able to wash my hands with zero twisting, pushing or pulling.

Like my legs, my arms and opposing thumbs suddenly seemed obsolete.

I never once had that feeling in Swaziland.

Here in the USA, automated effortlessness abounds. Even the security personnel monitoring the passport verification process were riding the thing pictured below. I don't even know what the machine is called...but the riders were not wearing helmets.

If we are no longer going to use our legs and arms, we can at least protect North America's brains until they too are eclipsed by supercomputers.

Only kidding, of course.

--

Next in this series: why saying hello is a unprofitable waste of time.

One hundred and one Swaziland destinations - #19: "The Swazi Cultural Village"

2007-10-11T16:06:00.001+02:00

I recently accompanied two friends to the Swazi cultural village to watch traditional dancing. I had been once before, shortly after arriving to Swaziland over a year ago. I felt less like a tourist the second time around. The cultural village is near Mantenga Falls, discussed in a previous post.

Here is a short video clip.

If "banana-ness" was a Platonic form... - Today's travel digest (1 of 10)

2007-10-10T15:07:00.000+02:00

I was last in the USA ten months ago. Until today, that is.

I am just off the plane from Africa, in the Atlanta airport. Though only back for a few minutes, I already find myself with a growing list of, um, transatlantic observations.

After clearing US customs (an interesting experience in and of itself), I proceeded directly to buy some coffee.

Despite forgetting that 'small' is now 'tall' and 'medium' is now 'grande' or something like that, I managed to convey that I wanted some coffee in a cup.

As I stepped up to the cash register and transacted with green money for the first time in a long time, I was struck by a a basket of yellow fruit on the counter. The contents looked a lot like bananas, but were much bigger and much much better.

I am not sure what Del Monte (the red, oval sticker on the mega-fruit read "Del Monte") does to coax flawless, foot-long bananas from the same earth that yields the brown, shriveled ones I have become familiar with, but they need to export the technology (produce life coaches?) to Southern Africa. Very impressive. I mean, I am very very impressed with those bananas.

Take the picture above, for example. Imagine banana #2 was perfectly yellow and 50% bigger. Now, extrapolate from banana #7 and imagine that there is an eighth. I have been eating #8s for a long time.

--

Stay tuned for my next travel digest entry on the universal automation/automatization of the American airport bathroom.

Your 5-day blog forecast

2007-10-09T10:16:00.001+02:00

The Spice Master's bounty.

I am getting on a plane in a few hours to fly to Texas for my pediatric board exam and some family time. Below are some of the upcoming blog entries that I plan to post. Maybe I will write them while airborne or while in the throes of jetlag-induced insomnia.

- Why AIDS is a disaster in the most literal sense

- The Spice Master: a Durban phenomenon

- The little devil of Zululand, and how to avoid its wrath

- A debriefing on last week’s training of trainers

- The high-kickers of the Swazi cultural village

Training trainers in Kwa-Zulu Natal, South Africa - Part 2

2007-10-05T19:39:00.001+02:00

I just arrived back in Swaziland from South Africa. The training went well. I will fill you in on the highlights "just now". (This phrase, as many of you know, is local slang for "soon, loosely defined".)

Seven highway hours require me to spend "now now" (meaning "now, literally defined") doing something besides sitting and typing.

Blogging is too much like driving.

I will, however, post the remainder of the cartoons (see below) that we use for counseling children with HIV. See Oct 3 entry for the original batch.

The reminder.

The HIV virus says, "Oh no!"

Giving the medicines.

Life on ARVs.

Stories about Sipho, Part 2 - A guest-blog patient encounter

2007-10-04T20:39:00.000+02:00

Please check out the (BLOG) RED link below for the second half of my recent patient encounter narrative about a child named Sipho. Click here for the first half.

(BLOG) RED: Stories about Sipho, Part 2

Training trainers in Kwa-Zulu Natal, South Africa - Part 1

2007-10-03T21:59:00.001+02:00

I have been in Pietermaritzburg, South Africa (near Durban) helping to give an advanced training on pediatric HIV care and treatment, and have had some difficulty finding time to write and post.

I will write and post soon, but in the mean time, have a look at the drawings below, which were taken from today's pediatric HIV counseling talk. (I have discussed the "soldier cell" analogy in several previous posts, including patient encounters with Siyabusa (July 2007) and Alshande (May 2007).)

The CD4 (or "soldier") cell.

Soldier cells protecting the body.

Soldier cell being attacked by the HIV virus.

The body's defenses being challenged.

The body's defenses weaken and the patient gets sicker.

The timeline for the HIV-infected body.

The revenge of ARV-armoured the CD4.

(Cartoons to be continued soon...)

Swazi HIV Awareness Poster Series - (12-13 of 20)

2007-10-03T21:54:00.000+02:00

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

2007-09-28T13:00:00.000+02:00

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

2007-09-26T15:33:00.000+02:00

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

2007-09-25T16:18:00.001+02:00

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"

2007-09-24T11:45:00.000+02:00

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)

2007-09-23T11:51:00.000+02:00

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

2007-09-20T16:43:00.001+02:00

“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

2007-09-18T20:30:00.000+02:00

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

2007-09-17T17:19:00.000+02:00

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"

2007-09-13T20:09:00.001+02:00

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

2007-09-12T15:18:00.001+02:00

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

2007-09-11T16:13:00.000+02:00

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

2007-09-10T16:03:00.000+02:00

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

2007-09-06T17:29:00.000+02:00

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

2007-09-04T17:44:00.001+02:00

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

2007-09-04T17:32:00.000+02:00

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

2007-09-03T12:40:00.000+02:00

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

2007-09-01T20:47:00.000+02:00

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

2007-09-01T20:37:00.001+02:00

A year and change - TV MDs and me

2007-09-01T09:52:00.000+02:00

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.

Addendum: Preparing oneself for multiple choices

2007-08-31T16:16:00.000+02:00

In my recent entry, I contrasted the working definitions of child health promotion in resource-rich versus resource-restrained settings. I implied that there is little that can be done in Swaziland to resuscitate struggling newborns.

While this is unfortunately the case, we are constantly engaged in capacity-building that is resource appropriate. When we participate in clinical training and mentorship, we use only what is available at the local clinic. All that I bring is a stethoscope, written reference materials and hand sanitizer. (Sometimes it is difficult to find soap.)

If you are new to the blog, you can check out a few of these clinics in previous posts (Links: St. Phillips , Shewula , Matsanjeni)

A couple of weeks back, thanks to the generosity of Operation Smile, our entire clinic staff spent the day receiving basic life support training. These skills are applicable to all clinical settings on all continents, and can certainly be used for neonatal resuscitation. To do it, all you need is you.

Here are some selected photos of our clinic staff from that day:

KT doing chest compressions.

Sipho and Eunice helping an infant who is choking.

Mlungisi, also performing the infant heimlich.

Today’s photo(s) from the Cape: Wine country– 5 of 10

2007-08-31T15:50:00.000+02:00

Mountains near Stellenbosch.

Cape Dutch architecture, circa 1700.

'Fair trade' in 1936,

Today’s photo(s) from the Cape: Wildflowers – 4 of 10

2007-08-30T09:15:00.000+02:00

It is wildflower season on the Cape Province's "West Coast".

Flowers.

Flower (2).

Flowers (3)

Helping a turtle across road. (Peculiar-looking creatures.)

Picnic on dunes (Nutella, olive paste, pastrami, cheese, bread, and Coke.)

Today’s photo(s) from the Cape: Kayaking – 3 of 10

2007-08-29T14:00:00.000+02:00

Not a bad way to spend an hour. There were whales that could be seen from the balcony of the beach cottage, but I could not find them. They are elusive, fast creatures.

Preparing oneself for multiple choices - Study break musings

2007-08-29T11:18:00.000+02:00

I have my "pediatrics board exam" coming up in mid-October.

Here is one of the practice items, an example of the type of question that appears on the exam:

“During the resuscitation of a 1.5-kg preterm infant who has apnea, you notice that inflation pressures of 15-10cm H2O for the first three breaths do not result in chest wall excursion, and the infants color remains poor. The heart rate is 90 beats/min. Of the following, the BEST next course of action is:
(A) administration of intravenous epinephrine
(B) administraion of intravenous naloxone
(C) chest compression
(D) endotrachael intubation
(E) Increase inflation pressure”

In most all of Swaziland, births occur at home, certainly premature ones. Even if they occur in the hospital, there are no newborn (much less preemie) face-masks to resuscitate. Except for a finger on the femoral pulse of the baby, there are no heart rate monitors.

IV meds, ET tubes, and mechanical ventilators there are none. Of course, there are no neonatologists.

So, why am I telling you all this on a blog that aspires to be upbeat?

Well, I have done several hundred of these pediatric boards "prep" questions over the last month, and there is not even a whimper about practicing pediatrics in resource-limited settings.

Here is the problem: almost all of the world's pediatrics is practiced in resource-limited settings.

There is certainly plenty of vile childhood illness here in Africa on which to base multiple choice questions. Most of these illnesses have inexpensive, relatively simple treatments...i.e. answers.

So, why doesn’t the American Board of Pediatrics test me on how to address the world’s most common illnesses in the plain, impoverished context in which most of the world’s illnesses are addressed?

Why not give me one question that asks me to help a child with limited resources at my disposal?

Now, I am assuming that you, the reader, are eager to point out that we are not tested about African children because US-trained pediatricians are almost all US-based pediatricians. We are, after all, talking about certification in the USA.

Good points. Now consider the following:

· In the USA, there are 28-165 pediatricians per 100,000 children, and the states with higher per capita income have more pediatricians.
· Before I came to Swaziland, a nation of about 500,000 under 18 year-olds, I was told that there was one in-country pediatrician. (I met her. She is great and works hard.)
· Baylor currently employs nine Swazi-based, US-trained pediatricians, as well as a family practitioner and two adult internists. This gives Swaziland around 2 pediatricians per 100,000 children.
· Meanwhile, 153 of every 1,000 children in Swaziland die before age five. In the US, the under-five mortality rate is 8 per 1,000.

I understand that it is a good thing that US-based pediatricians are able to spend thousands of dollars to help save the life of a child. It is not a surprise that our credentialing process reflects that.

But, does our credentialing body not agree with me that child health is global by definition, that a healthy, sick or dead child is still a child, regardless of nationhood?

The American Academy of Pediatrics’ states that it is “Dedicated to the health of all children.”

Great.

The American Board of Pediatrics, who administers my certification exam, strives to promote “high quality health care for infants, children and adolescents.”

Admirable.

My point is this:

Either these mission statements need to end with the words “in the USA” or the AAP and ABP must strive to encourage American pediatricians to reflect on child health promotion in resource limited settings.

At least one question.

Gotta go. Off to study.

Refs:
PEDIATRICS Vol. 116 No. 1 July 2005, pp. 263-269
PEDIATRICS Vol. 100 No. 2 August 1997, pp. 172-179

Happy birthday Dad and Sis!

2007-08-28T11:02:00.001+02:00

Today is my father's (Charles Ray Phelps II's) and sister's (Sarah Jayne Hathcock's) birthday.

Please see this short video to mark the occasion.

(Oh, I am also afraid that I was allocated little on-screen, uh, "star quality", so do not expect anything Oscar-worthy. I thought about trying a second take, or maybe something scripted, but my beloved family traditionally prefers informality and imperfection when it comes to this sort of thing. We reserve our 'A game' for horseshoes, trout fishing, and Texas Hold-em poker, among a short list of other things.)

Today’s photo(s) from the Cape: Kite-surfing 101 – 2 of 10

2007-08-28T07:04:00.000+02:00

Learning to fly the kite (1).

Learning to fly the kite (2).

James, my instructor, who knows how to fly the kite quite well (1).

James (2).

Today’s photo(s) from the Cape: Sundown studying – 1 of 10

2007-08-27T08:59:00.000+02:00

This week, I am in Cape Town, South Africa. I am here to do some studying for the “pediatrics board exam” (which I will be taking in October) and to wander around a bit.

Not-so-candid me running through some exam prep questions on my computer.

An Atlantic-Sun rendezvous, marking another day's end.

My generous terpsichorean hosts, Catherine and James.

ANSWER: Swazi 'cultural competency' pop quiz (Question 7 of 10)

2007-08-25T18:01:00.000+02:00

ANSWER= (d) Enema instrument.

Well, I finally bought one of these. (My dad's birthday is coming up on the 28th of the month. Happy birthday, dad!)

The one pictured cost USD$4.50 and was purchased at the roadside shop pictured in the previous "pop quiz" post.

I am not sure of the exact statistics, but these are very commonly used for "cleansing", especially on Sundays, and are often found hanging in private latrines here in Swaziland.

Now you know.

Burdened hunters – Cultural encounter series (1 of 10)

2007-08-22T18:05:00.000+02:00

On my way to work yesterday, (like the day before, a 2 hour drive each way), I looked out the window. I had tried reading during the drive and found myself little smarter and much sicker. (Something about the UNICEF truck, the vehicle we use for rural site visits, disagrees with my inner ear, stomach, and all of those other body parts that are afflicted when car sickness sets in.)

On my protracted commute, I saw crowd of people, mostly women, with wheelbarrows. They were awaiting the delivery of powdered maize to sustain their families. Children used the wheeled vehicles for cots, seats, or shade, depending on their size and age.

I saw a child laying across three empty twenty-some-odd liter water jugs in the morning sun at the minibus stop, likely awaiting pubic transport to the muddy river down the valley. Despite the magnitude and seeming impossibility of his errand, and despite the dirt devils that sprung to life in the wake of passing trucks and powdered his clothes and jugs, wore a relaxed, reflective expression.

I saw women with bundles of wood balanced carefully on their heads, each bundle longer and by all appearances heavier than the body shuffling beneath. They were for building or burning, I know not which.

I saw a semicircle of people bent at the waist around the newest deposit of municipal garbage at the landfill outside of Manzini, Swaziland’s largest city. They picked through colorful plastic bags for something worth more than trash, something that could be eaten or sold.

I saw a grazing wildebeest, one of the few respites my eyes found between these and other incessant high-speed snapshots of impoverished human beings.

Human beings sitting hungry, thirsty and dusty atop the food chain.

Why I love my job - Quote 11 of 20

2007-08-22T12:36:00.000+02:00

“I have got a little doctor behind me.”

– Vusi (a proud father) commenting on Siphesihle (his 6 year-old daughter) playfully listening to his back with an imaginary stethoscope, shortly after I did so with an actual one.

Siphesihle is thriving on ARVs.

For quotes 1-10, click here.

Addendum: One hundred and one Swaziland destinations- #13: Matsanjeni

2007-08-20T16:50:00.000+02:00

Rita at her desk, which is home to several dozen of today's patient files, an appointment roster, an ARV roster, female condoms, male condoms, and plenty more.

Today was another one of those long there-and-back days. Matsanjeni was the there.

Total travel time 4.5hrs. Total mentoring time: 4.5 hours. Total patients seen: 35.

For those of you who have not read about Swazi destination #13 (and Rita), click here.

Swazi 'cultural competency' pop quiz (Question 7 of 10)

2007-08-20T16:40:00.000+02:00

The photo below is of poor quality. I work hard not to rubberneck, and so did not dwell long when shooting. I searched diligently for online images of this device and found none. Basically, they are coffee cans with a clear plastic tube attached. My question for you is this: What are the things hanging up?

(a) Dispensers for cattle dip (i.e. for livestock deparasitization, esp ticks)
(b) Tubes for siphoning or filling gas and oil tanks
(c) Maize mealie meal storage/dispensing canisters
(d) Instruments for self-administered enemas
(e) Feeding tubes for parentless or disabled baby domestic animals

Today's patient encounter

2007-08-16T14:11:00.000+02:00

This is Bayanda. He is 8 months old. He started ARVs today. More on him soon.

ANSWER: Swazi 'cultural competency' pop quiz (Question 5 and 6 of 10)

2007-08-16T13:35:00.000+02:00

The answers and explanations correspond to questions 5 and 6 below. The questions relate to Swazi destinations #14-15 (also below).

#5 Answer: (a)
#6 Answer: (c)

If any of you Swaziland aficionados know the explanation for these seemingly disparate correct answers, please let me know. I have asked around, so far to no avail.

Reparations in La Mancha - A patient encounter

2007-08-15T08:26:00.000+02:00

www.wikipedia.com

She wore a deep ink-blue head scarf with little white windmills on it. I wondered where she had purchased the fabric, for I have yet to see a windmill in Swaziland.

She appeared tired, and it was not because of immunocompromise or illness, for her CD4 was quite high and her body showed no clinical evidence of HIV infection.

I told her this. She responded indifferently with the subtlest nod of recognition, her eyes never rising from her folded hands.

On her previous visit, she had been fast-tracked because her infant child was admitted in the local government hospital, and she had to return to the ward quickly to ensure her child was fed, medicated, and all of those hospital-specific activities that are handled by actual nurses when they are not overworked and under-trained.

This visit, the mother had waited in the queue with the rest.

While I wanted to believe that the child was playing happily and healthy at home, I knew the answer to the question I was about to ask.

“How is your baby?”

“He died,” she said, still looking down into her hands, which suddenly appeared quite empty.

The confirmation gave me that hellish feeling that one has when temporarily unable to convince himself or herself that the world is a good and fair place.

I said something to the empty-armed mother, something entirely inadequate. The well-intentioned words left my mouth with a pretense of grace and immediately fell to the floor with a clumsy thud.

They fixed nothing.

“What happened to the child?” I asked.

While she spoke in SiSwati, a swoop of her hand over her lap told me that the child’s belly had grown very large in the final days. She then held her hands out as if holding her child by the head and trunk, and brought them together, pantomiming the weight loss that preceded the child’s demise.

When she finished speaking, as a tear escaped the mother’s dulled, icy, otherwise indifferent eyes, the translator to me that “the stomach grew very big and the baby was losing weight. The baby died Saturday.”

The hellish feeling returned. I manufactured a few more well-intentioned, sympathetic words trying to inject something besides sadness into the sorrowful, hardened woman. I then wrapped up the visit, unable to repair the irreparable.

For an instant, I sat alone in my exam room wondering if addressing global pediatric HIV was somehow hopeless, absurd, quixotic.

Then, after the briefest instant, I decided it was not.

Ashamed that the thought even crossed my mind, I stood up to call the next patient.

He was a happy, healthy child, thriving on ARVs.

Monday - A minute-long patient encounter

2007-08-13T16:21:00.000+02:00

Several events conspired to make this Monday a challenging one.

After a difficult day, I sometimes pull up the two photos below and look 'em over for a minute or so.

Happy Monday.

Severely malnourished, immunocompromised child.

The same child after ARVs.

"Monday's child is fair of face.

Tuesday's child is full of grace.

Wednesday's child is full of woe.

Thursday's child has far to go.

Friday's child is loving and giving.

Saturday's child works hard for a living,

But the child who is born on the Sabbath Day

Is bonny and blithe and good and gay."

- Monday's Child (a nursery rhyme)*

*Actually, it seems that I should be most weary of Wednesdays and Thursdays.

One hundred and one Swaziland destinations - #16: The Ngwenya Glass Factory

2007-08-09T18:05:00.000+02:00

The Ngwenya Glass Factory is one of the more often cited tourist stops here in Swaziland.

I included it because, well, bright orange glowing molten glass is quite a sight.

It flows like cold molasses and luminesces like lava.

The photos below depict the the activity on the glass factory floor and a few of the products.

The factory floor. An occupational hazard mine field.

Glass blower.

Kiln and sweating artist.

Vase.

Vase 2.

Elephant 1-5. They also make hippos, lions, etc. etc. etc.

Swazi 'cultural competency' pop quiz (Question 5 and 6 of 10)

2007-08-09T17:54:00.000+02:00

The following questions will test your knowledge of Swazi destinations #14-15 below:

#5. Both homesteads pictured have a round hut on them. This is traditionally called:
(a) The granny house (or “Kagogo” in SiSwati)
(b) Young men house ("Lilawu” in SiSwati)
(c) Married man’s house (SiSwati name not retrievable)

#6. This round hut is the place where:
(a) The dancing occurs
(b) The marital bed is situated
(c) The children sleep and the food is prepared
(d) The grandmother, or gogo, sits to give advice in the evenings

One hundred and one Swaziland destinations- #14 & #15: Two Swazi homesteads

2007-08-07T17:05:00.000+02:00

Dallas is a city. Mbabane (where I live here in Swaziland) is almost a city. Well, let’s just call it a town. It is big for Swaziland, but it is a town. 80K inhabitants or so.

In any case, most of Swaziland, just like most of Texas, is rural.

The quintessential Texan is not a Dallas real estate agent or a Houston banker. He is a cowboy, a farmer.

Well, so it is in Swaziland. Folks live and make their living out on the countryside. They live in homesteads like these.

A traditional homestead, on the way to Matsanjeni Health Centre (see below for more on Matsanjeni)

A more modern homestead along the same road (note the electrical wires).

Counting to three – three patient encounters

2007-08-06T12:40:00.000+02:00

The summary page of the Baylor clinic’s electronic medical record contains most all of the information one needs to guide a patient visit, including an “issues for follow-up” box.

One morning last week, I saw three patients with the following issues for follow-up.

Patient #1, age 3 years: “Cough; mother died.”
Patient #2, age 8 months “On TB treatment; mom died 7/7/07; thrush”
Patient #3, age 4 months: “Mother deceased (need to clarify TB status of mom); pneumonia, HIV DNA PCR pending”

A year ago I would hear a word like “body count” and think of crime dramas or war documentaries.

Now that I have done the counting myself, I just think of people my age or younger who have died, many of them leaving parentless children.

These are too many parentless children here.

Still, the counting continues.

--

I hope that I continue to get better at what I am doing.

I hope that we continue to do more and more.

I hope that some day there is more counting down and less counting up.

I hope this dearly.

One hundred and one Swaziland destinations- #13: Matsanjeni

2007-08-03T14:03:00.000+02:00

Matsanjeni is one of the health referral centers in the Shiselwini region of Swaziland, essentially making up the bottom third of the country. It is a dry hilly part of the world. If I were to do a watercolor of the landscape this time of year, water and an earthy brown color would suffice. In late winter, the only exceptions to this are the colorful woolen clothing of the inhabitants and the bright orange flowers that adorn the area’s large and ubiquitous aloe plants.

Otherwise, it is a dry land of diluted browns.

Of course, the pied spring will come soon enough. Then, the toaster-oven-summer.

During this time, it is my hope that Nurse Rita and I will be able to entice the children of surrounding Shiselwini to come in for HIV testing and treatment. As of now, they only have thirty something children on ARVs, and this represents but a small fraction of the catchment area’s infected children.

For this reason, every 2 weeks, I make the two-hour drive to Matsanjeni to mentor Nurse Rita, who is very comfortable with ART in adults but timid when it comes to pediatric HIV care.

Over the past two months, Rita has begun to schedule children on the day that I am scheduled to visit. On my first day at the health center, there was one child. Last week, there were six. Next time Rita expects to double that.

When the rains have come and gone and the colorful but punishing summer replaces the cool dusty earthtones of wintertime Matsanjeni, I am confident that we will be sweating alongside several dozen newly-discovered pediatric patients.

When the weather again begins to cool, I will have taught Rita all that I know, and she will be ready to manage HIV+ children herself.

--

Matsanjeni is one of three outreach sites where I have worked.See the following links for the other two:

One hundred and one Swaziland destinations #9: St. Phillips
One hundred and one Swaziland destinations #10: Shewula

Baby skin - A patient encounter

2007-08-01T15:58:00.001+02:00

It was not the kind of rash you have to lean in to see, but I wanted to get a better look.

When I approached Mluleki to look at his skin, he started giggling.

Soon he was guffawing.

Seven month-olds are usually a little more tepid when I approach them, but Mluleki was not. He was convinced that I was playing with him, and he found our game simply hilarious. His eyes followed me, waiting for the next subtle excuse to burst into gleeful laughter.

He is what I will call precocious socializer.

I am what I will call a clinical opportunist.

Since he was having so much fun, I pretended to play along while actually leaning in further to scrutinize the irregularities on the child’s face and neck.

As I did this, there was little hilarity to be found.

The red bumps were everywhere. In places the bumps were covered with thick golden scabs resembling corn flakes. In the areas that the child could reach and scratch, there were bloody scabs of deep purple. In the middle of his forehead, there was an area where his skin pigment had eroded away from the crusting and scratching. The exposed blush-white tissue beneath contrasted sharply with the skin around it.

Areas that were not crusted or depigmented were raw-steak-like.

Mluleki's face was a mosaic of skin pathology.

But, oh my, how this child did laugh as I examined his pathological, bleeding, dichromatic, caked-over, raw-steak-like skin.

Mluleki may or may not have HIV. His skin tells me that he probably does but final diagnostics are still not back, and, in addition to being opportunistic, I try to be optimistic as well.

With effervescent children like Mluleki in the exam room, this comes easier, no matter how pathetic and sad their inherited afflictions.

Of course, regardless of his HIV status, Mluleki’s skin should get better. It should someday be smooth, scabless, and evenly pigmented. It should someday cease to resemble uncooked beef.

I don’t care how many medicines it takes to make this happen.

A baby deserves to wear baby skin.

Mluleki deserves to laugh beneath a humane complexion.

No birthday suit should be allowed to succumb to such badness before it has seen a birthday.

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

2007-07-31T19:56:00.000+02:00

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)

2007-07-30T20:05:00.000+02:00

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

2007-07-28T11:23:00.001+02:00

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

2007-07-25T17:54:00.000+02:00

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)

2007-07-24T17:33:00.000+02:00

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.