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.

The sky is falling – A tale of natural disaster

At first I thought someone had thrown rocks through my windows. Then I thought better. Swaziland, after all, is not a violent place. Nor does the rock hypothesis explain the rest of the damage.

As I looked around my house, I saw fallen trees, grounded power lines, holes in neighboring roofs, and, scattered throughout the lawn, branches and white plastic. The white plastic was a bit of a mystery until I realized that the plastic gutters lining my roof were swiss cheese, and each plastic piece corresponded to an identically shaped hole overhead.

While I still have no notion of how they make the holes in swiss cheese, I quickly realized that my Swazi homestead (and its gutters) had been the victim of a sizeable hailstorm.

The air was cold. Really cold. Not Africa-in-summer-time-unseasonably-cool, but cold.

A group of my colleagues and I had been in Mozambique for the weekend and arrived home at dusk last night, an hour or so after the storm, when we first noticed the carnage.

I was glad that we had stopped for a half hour for gelato on the way out of Maputo, and that we had been detained for a similar time period by a stern, ill-tempered Mozambican highway patrol cop. That had saved us from driving through during the frozen barrage.

As soon as we switched our phone cards to the Swaziland network, we began hearing the stories. A man hit in the face by falling ice, now at the hospital for reparative surgery. Ice penetrating tiles and wood around Mbabane and landing in peoples living rooms. Ice destroying cars, crushing windshields. Hail the size of small cantelopes.

I am no meteorologist, and I am no physicist. If I were, perhaps I would understand how a chunk of ice smaller than a small cantelope remains airborne long enough to reach a small cantelope’s size. As a non-weatherman, I assume that a bit of airborne ice must be like a snowball rolling downhill, gathering mass and momentum as it descends, until eventually it crashes missile-like to earth.

One does not come to Africa expected to be bombarded with large chunks of ice from the sky. I expected swelter and sweat, not melon-sized hail, especially in December, one of the subcontinent’s hottest months.

--

According to those watching the storm, the hail lasted a minute or so.

I wondered if anyone had died. (I will check the newspaper.)

I wondered if, for that one minute, the hail storm caused as much damage to Swaziland as HIV did.

If HIV fell from the icy sky and broke things, would we pay it more attention?

You have the wrong hospital - A virtual tour

“You have the wrong hospital.”

These words greeted me the first time I drove up to the gate of Mbabane Government Hospital (MGH).

“The private hospital is across town,” the guard continued.

“No, no, I am a doctor coming to work here in Mbabane, and I want to see the hospital.”

“You are not here for sickness?”

I wasn’t sure how to answer that question. Sickness was certainly involved in my decision to leave the United States, join the Pediatrics AIDS Corps in Swaziland, and find my way to Mbabane’s primary pediatric referral center.

“I am not sick, but will be working with many of the sick children here.”

That was quite some time ago, and I have indeed worked with many of the sick children here. This past week, after nearly three months of working primarily in the outpatient HIV clinic supported by Baylor, I spent a few days at MGH seeing patients alongside the doctors and nurses there.

While it is still fresh on my mind, I wanted to offer you a short, virtual tour.

The pediatric ward of Mbabane Government Hospital is known as “Ward 8”.

Just before you enter this ward, there is a large ORT/Nutrition room to the right, where children spend the day if they need oral rehydration (the T in ORT stands for “therapy”).

Children present to Ward 8 for many reasons, but among the most common is diarrhea, malnutrition or both. This is not an easily-solved problem, considering that children are usually subject to an unsafe water supply and food insecurity for a long time before arriving to Mbabane Government Hospital. Recuperating from a long-term, progressive condition requires time, and it is difficult to ensure that a severely malnourished child gains weight. For this reason, the ORT/Nutrition room is staffed by two very kind nurses to oversee this process. One of these nurses is named Happiness. If you find yourself entering Ward 8, pop in to tell her hello, for she is appropriately named.

As you enter Ward 8, you will notice that it is bisected by a long hallway. There are three large rooms off the hallway to the right, and there are several smaller rooms off to the left. The first door you reach is on the left, and it is the Pediatric Intensive Care Unit (PICU). To those trained in academic centers in the developed world, intensive medicine is defined by supporting fundamental physiologic functions, like, for example, helping a child to sustain dropping blood pressure, maintaining electrolyte balances when the body’s regulation falters, mechanically filling the lungs with air when a child cannot do so on his or her own, or even monitoring and controlling the pressure inside of a child’s skull to prevent brain loss or death after trauma (usually mechanical) to the central nervous system.

In Ward 8, intensive care means something quite different. The 4-5 children in the PICU at any given time are those that most need oxygen, for there are functioning O2 ports built into the wall of this room, a rarity in other locations. Beyond this limited support, in addition to standard IV fluids and possibly medications from the hospital’s strained pharmacy, the child must maintain her or his own vital signs. In many cases, the children do. In the cases where they do not, another death follows, in most cases a preventable one.

If you continue down the hallway of Ward 8, you will pass a small workroom on the left, where nurses and doctors congregate when not at the bedside. The room is plain, with only various bulletins adorning the walls, many from past HIV/TB public health campaigns.



If you find yourself peering in this room, you may notice that uniformed nurses within eye you suspiciously. Don’t mistake it for hostility. This is the look they give the “short-termers”. Rare is the visitor to Ward 8 that stays longer than a few days or weeks. Most new faces, I would guess, stay but a few minutes, seconds even.


Don’t get me wrong. Short-termers care immensely for the children in Ward 8, and they want to help, to make things better, to change things. They are usually deeply moved by what they see on the ward. I suspect you will be too.

I know about short-termers because I have spoken to them as they wander through Ward 8. I know about them because I myself am one.

The nurses are not short-termers. They went to nursing school because they too want to make things better in Swaziland, and they want to do it for a living. Most of them are Swazis, and were trained at the local university. The Swazi nurse uniform they receive at the end of this training is more like a military garment than the cheery, flowery scrubs that U.S. nurses wear. The Swazi nurses wear their uniforms proudly.

They can be found in Ward 8 every day, in uniform. They see a child die on many of those days. There is little cheer in this, and usually little they can do about it. There are around a dozen nurses that rotate through Ward 8, but only two or three on at a time. The average patient census is around forty, the children are often very sick, and supplies are few.

Between checking on the 25 sick children under their care, they might look at you suspiciously, but don’t take it personally. It is just that they have heard the short-termers’ words of encouragement, the promises, and still, a year or more later, they are working in an ill-equipped, crowded ward, except this year the ward is slightly more crowded because more children are presenting with acquired immunodeficiency syndrome.

You see, HIV treatment for kids, available for many years in rich countries, is just now becoming consistently available in Swaziland. As the Baylor clinic and its partners scale up such treatment, the inpatient pediatric census will likely drop substantially, but for now up to 80% of the children are HIV-positive.

Though I would like to promise the Ward 8 nurses that we will decrease the number of children in the hospital, I refrain. They would only eye me suspiciously, and rightly so. I have been in the hospital a total of four days, in Swaziland for three months. I am a short-termer.




Continuing down the hallway, we come to Cubicle #1, the first large room on the right. Before entering, you can see through the glass panels that there are approximately 12 cribs lining the walls, except for the far back corner which has a long platform with dividers, where infants can be laid side-by-side. Up to three patients can be assigned to each crib, but usually there are only one or two. Beds are shuffled around as needed for older patients.

The room itself is not unpleasant. It is recently painted, with at least some perceivable ventilation through the back windows. The temperature in the room, as a result, is actually agreeably temperate. The primary smell is faint and is that of kerosene, which is sometimes used as an antiseptic for the floors.

Each child is coupled by a caregiver (usually the mother, aunt, or grandmother), who provides for the child’s basic needs. The hospital provides the food (though the formula supply is sometimes interrupted), and the caregiver feeds the child. The nurses’ role is to administer medications, troubleshoot and coordinate patient care with the doctors.

Cubicle #1 is reserved for kids with infectious disease diagnoses. Most of the patients have a respiratory ailment (pneumonia, tuberculosis, asthma, etc.), but diarrhea, meningitis, and others are not uncommon.

Neighboring Cubicle #1 is Cubicle #2. It is reserved for surgical patients. Children recovering from accidental trauma—complicated burns, fractures, etc.—are monitored here. (Such trauma is not uncommon in Swaziland, given open-flame cooking, lax traffic laws, and the density of pedestrians along major roadways.) Children with other surgical needs (intestinal obstruction, ostomy revision, appendicitis, mitral valve insufficiency, etc.) are also assigned to Cubicle #2.

As you arrive at Cubicle #3, you will notice a small mural on the left. The painting depicts many of the characters from Disney’s The Lion King. It is nice to look at, and seems to be the project of a former short-termer, as it is beginning to show signs of wear.

Cubicle #3, the last door on your right, is for chronic patients, namely those that need intensive nutrition or long-term antibiotic therapy. They are segregated from Cubicle #1 to control infection as much as possible, but patients with TB (diagnosed and undiagnosed) can end up in any room.

Swaziland has the highest rate of TB in the world.

The cubicle system is certainly not perfect, but lest you find yourself surprised by this, I will point out that Ward 8 does not always have running water, much less soap. N-95 masks, HEPA filters, negative-pressure rooms, individual patient isolation are science fiction here at MGH, regardless of your TB status.

On that note, if you want to diagnose military TB or TB of the spine, you have to do so without cross-sectional diagnostic imaging. Pictured below is the local government hospital's cat scan machine. It broke some time ago and there are neither the parts or the expertise to fix it. The elevator met a similar fate, so the cat scanner was placed where pictured to keep patients from entering in the stagnant elevator car.




This brings us to the last door on the tour. Through the door there is a small room, about five square meters. Some call the room the “laundry room”, for indeed it is where the sheets and other linens are washed. I have heard others call it the “room for abandoned children.” Indeed, the room is also full of children without a home.

The children are between 1 month and ~10 years of age, and most appear relatively healthy (though a good proportion are suspected to be HIV positive). They all have different stories. Some are orphans. Some are developmentally delayed. Some just moved over from Cubicle #3, having nowhere else to go, and nobody to go to. Regardless of the events leading up to their confinement to the back of Ward 8, they were now under the care of a few dedicated women who feed, change, and clothe them between loads of laundry.



This concludes your tour.

--

Any walk through of Ward 8 forces the walker to ask difficult questions. I am not an expert in asking difficult questions, and am the most amateur of amateurs in offering meaningful answers to these questions. Such answers, I might add, are well beyond the scope of this blog, and well outside of my zone of personal comfort.

With that said, I will quickly address one question that often nags me when I am faced with unnecessary childhood suffering and death. The question is this: When a child suffers or dies a preventable death from a treatable disease, is it because that child is less valuable to those in charge of protecting him or her from harm?

My answer: No.

As I see it, there is a difference between the capacity to love and care for another human being and the capacity to intervene. I have seen too many desperate, mournful mothers and fathers to believe that indifference blunts the pain when a child hurts or dies.

Love and care are fundamental to humankind, and they cost nothing. Intervention, on the other hand, is not free. The capacity to love and feel is inborn, but the capacity to place a child who cannot breathe on a ventilator is not. It is expensive.

Rare is the society that can support high-dollar intensive care medicine for children.

Very rare is the society that does not wish to defend the health of children and does not wish for a state-of-the-art children’s ward and PICU.

Extrememly rare is the opportunity to have wishes come true when you live in a country where the vast majority are feeding, clothing, and sheltering their family on little more than a dollar a day.

--

Yesterday, a Swazi told me a story about a group of four children he came across near his small village in the hot, dry eastern lowveldt of Swaziland. The oldest was approximately 10 years of age, and she was accompanied by three younger siblings. The 10 year-old was wearing underwear, and the others were completely nude.

The four naked children, he explained, had been walking for 30km looking for their grandmother. Their mother had died the day prior, and the oldest child had led them on a search for their nearest known relative.

The 10 year-old was confident that they were almost there.

--

My answer to the above question is “no” because I am certain that the mother of these 4 children did everything she could while alive to ensure that her children would not have to walk nude and aimlessly across arid countryside in search of someone to feed, shelter, and clothe them. She did all she could, but it was not enough.

Poverty and sickness did not make her care less. Poverty and sickness took away her ability to protect her children from becoming orphans with no place to go.

To understand Ward 8 and the values assigned to the lives within, it is necessary to first understand this country’s poverty and the sweeping effect of HIV/AIDS among its people.

This understanding is not acquired over the short term.

Collision course - A training day

“Look out, Sister Mamba!” one of the nurses shouted.

I had never hit a nun in the head with a chair, and was at dire risk of ruining my perfect record. We were trying to fit two dozen human bodies in a room designed for a half dozen, and we were short on chairs. To move furniture in the crowded room, I had to hold it above my head and above the veiled head of one particular elderly, paradoxically-named, surprisingly tall nun.

I am not entirely sure of what I was daydreaming about at the time, only that I was daydreaming. I remember noticing the view from the training room, and how it reminded me of the western North Carolina except all of the pines were planted by a timber company for harvest. I remember seeing a photo of the king on the conference room wall and wondering why he had three red feathers in his hair rather than two, four, or some other number. I may have been thinking about standing outside our clinic the previous afternoon and watching two toddlers chasing each other through the grass, giggling. The one in the lead was carrying a pink backpack over her head in what seemed a game of keep-away. I had refilled her HIV meds the week prior, and had wondered if they were in there, jostling about.

Regardless of what was distracting me, the Sister wasn’t exactly paying adequate attention either. She was talking to her coworker while walking backward toward the corner where I was shuffling steel furniture. Walking blindly in a crowded room during remodeling was risky behavior, especially for a church lady.

Still, I was definitely going to receive all blame if a collision occurred, my not being a nun and all. Knowing this, I executed a quick pivot and awkward but heroic hop, and the collision was averted. More importantly, my soul narrowly dodged eternal hell-fire yet again.

With Sister Mamba and the rest of the group safely seated, we started the day. After a brief review of the previous day, I began the next segment, a two-hour behemoth of a lecture on opportunistic infections (OIs).

I looked out over the faces of the 24 nurses and began my “brief” overview of the diseases that kill their HIV positive patients.

Though the nurses could not fast forward through my two-hour lecture, we can.

Here we go.

“HIV does not kill patients; OI’s kill patients” >>> Tuberclosis >>> Pneumocystis carinii (Pneumocystis jiroveci) >>> Lymphocytic interstitial pneumonitis >>> Candida albicans >>> Varicella zoster virus >>> HHV-8 (Kaposi’s sarcoma) >>> Cryptosporidium parvum >>> Cytomegalovirus >>> Mycobacterium avium-intracellulare complex >>> Toxoplasma gondii >>>Cryptococcus neoformans >>> “Let me wrap up with immune reconstitution syndrome, where your patients appear worse as their immune systems recover after starting ARVs.” >>> “Remember: prevention of OI’s involves careful treatment of HIV, good hand-washing, cooking food, boiling water, etc.” >>> “Any questions?”

One of the nurses in the back raised her hand.

“What if we don’t have running water?”

“Well,” I said, “that can be a challenge. When patients don’t have access to running water, I usually…”

Her hand went up again.

“…I mean if we don’t have running water in the clinic.”

“Well…um…” I had no idea how to answer the question, so I answered with a question.

“How many of you do not have running water in your clinics?”

Around a third of the hands went up.

One of the participants not raising her hand said, “We have water sometimes.”

“Okay. Raise your hand if you don’t have a reliable water supply in your clinics.”

Three quarters up.

“Damn,” I thought, realizing that I would be rotating through many of these clinics in the year(s) ahead.

As a group, we brainstormed solutions to this problem. Water tanks, homemade sanitizing hand gel, digging additional bore holes, etc.

“Any other questions?” I asked, afraid of what might be divulged. Hearing none, I quickly adjourned my portion of the morning.

---

One of my colleagues called HIV in Swaziland “an apocalypse.” Indeed, the numbers paint a frightening picture. Projections into the years ahead are scarier still, with concerns that countries like Swaziland could actually someday require repopulation.

How do you counter an apocalyptic pandemic without running water?

Later in the workshop, we discovered that most of the clinics in Swaziland also have no laboratory, and that all have very limited access to medicines, with long, unpredictable interruptions in the supply of those they do have.

We did not ask the nurses their salaries, but it is safe to say that few Swazi nurses are able to save enough to buy a car.

I wonder how these nurses feel when they walk into their own clinic and are greeted by an overflowing waiting room. In that clinic, they stand alone against an incessant flood of disease and need, at times without even a trickle of water from the sink.

When I picture this, the typical workday of a rural Swazi nurse, the word ‘underdog’ seems an understatement.

Yet, somehow, they persevere. They preserve hope.

On the fourth and final day of our training, we asked the nurses to divide into small groups and discuss the challenges faced by their individual clinics, as well as potential solutions. After doing this, they presented their ideas, and training certificates were distributed.

As the nurses stowed their diplomas and prepared to leave the cramped conference room and board the even-more-cramped public minivan that would return them to their rural clinics, Sister Mamba raised her hand.

The eyes of the room converged on her white gown. The sister had been quiet during the training sessions and the nurses were curious to hear what she had to say.

She stood.

“HIV is the challenge that will define our generation,” she said. “Our generation’s challenge is that we have much work to do. We cannot only describe the problems. We must return to our clinics and work to solve the problems. We must.”

She sat.

In the room, there was silence.

More silence.

Still more.

…probably 15 seconds total.

…20.

Sister Mamba suddenly stood again.

“That was my conclusion and it need not be challenged.”

She sat, chin held high.

The nurses in the room smiled a collective smile, and then applauded. I smiled and clapped along with them, glad I had not hit Sister Mamba in the head with a steel chair.

Teaching pathology - A training day

Teaching pathology: a training day


“How many here have done HIV trainings before?” Dr. Delouis asked. About three-quarters of the 28 community-based nurses in the room raised their hands.

“How about pediatric HIV?”

All hands sank.

“Okay,” Dr. Terlonge said. (I believe this response was short for, “Okay, well, at least we are in the right spot.”)

‘We’ were a group of four American-trained doctors. Three pediatricians and one preventative medicine specialist. We were from San Francisco, New York, New York, and Denison, respectively. That makes three city slickers and yours truly.

We were about to begin a 4 day pediatric HIV training course at the Piggs Peak Government Hospital, approximately one hour’s drive north of Mbabane, Swaziland. Nearly all nurses from the hospital’s catchment area were in attendance.

We were there because, as reflected by Dr Delouis’s informal show of hands, it has been the tendency of developing world HIV programs to focus on adults. They are, after all, the productive population that works and pays taxes. They are also the re-productive population that has sex.

Dr. Delouis explained that, as pediatricians, we were there to introduce them to HIV in kids, beginning with the epidemiology and pathophysiology of pediatric HIV, followed by diagnosis, care for the HIV positive pediatric patient, nutrition in HIV, prevention of maternal to child transmission, etc.

After Delouis spent an hour reviewing the magnitude of Swaziland’s epidemic (summary: very large in magnitude), it was my turn to speak. I was to discuss the pathophysiology of HIV in children (physiology being how HIV behaves and replicates; pathology being how it messes things up).

Physiology and patology talks can be quite boring, so I had been thinking about strategies to spin the topic to the audience in such a way that it seems more interesting.

I needed a hook, if you will.

My father’s name is Dr. Chuck Phelps. He is an avid fisherman, and he knows hooks well. He grew up near the lake with the best striped bass (or “striper”) fishing in the world (or at least I have been told this). I grew up there too. It is a lake called Lake Texoma, and it is called this because it was formed in 1942 when the Red River dividing Texas and Oklahoma was dammed.

For every striped bass in Lake Texoma, I estimate that there are at least three types of hooks that have been designed to get these fish from the water to the boat. My father knows them all. He knows when to use them (dawn, dusk, deep water, shallow water, northerly wind, southerly wind, and so on and so forth). He knows how to use them (reel in slow, reel in fast, make the lure splash, make it sway, make it dance, jiggle, sink, float, pop, slither, juke, bounce, slide, meander, pause, surge, pivot, shimmy, spin, roll over, play dead and so on and so forth). He know where to use them (near the dam, near the Lowe's Highport islands, near Eisenhower Marina, on the rocky Texas shore, on the sandy Oklahoma shore, and so on and so forth).

As far as the ‘why’, my father fishes because he likes spending time outdoors. He fishes with me because he likes spending time with his eldest son. He likes sharing his knowledge of the lake he grew up on. He likes to take fish home and fry them with potatoes and hushpuppies. He likes to sit down with his wife and three kids and share the fried striper he caught and prepared.

My father fishes because he likes to honor and relive the memories of doing the same with his father, my grandfather, who I never had the privilege of meeting. His name was Dr. Ray Phelps, and he was north-central Texas’ first pathologist.

He moved there because he liked the lake, and he wanted his kids to grow up in Denison, Texas. He moved there because there was no pathology department in the local hospital, and therefore no mechanism to routinely examine disease on a microscopic level, the level at which all disease operates. As Dr. Ray was an expert on the microscopic workings of disease, he received a warm welcome in Texomaland.

I didn’t have the opportunity to ask Ray why he become a pathologist, but I imagine he was interested (as I am) in how disease meddles with normal human physiology, how it interrupts the health and integrity of the human body, one tiny cell at a time. I wonder if Dr. Ray Phelps was moved (as I am) by the pain that these tiny pathologic malfunctions can inflict on a previously healthy human being, no matter how young. I wonder if somehow learning how all of the malfunctions look under the microscope offers some comfort that sick tissues might someday regain function.

It was time to start the lecture.

Still, no hook was coming to mind.

My first powerpoint slide was a photo of my extended family on the stuffed bucking bull in Ft. Worth, Texas’ “Billy Bobs”, the self-proclaimed largest honkey-tonk in the world. The photo, as shown, was taken on my recently elapsed 31st birthday.


“What does this make you think of?” I asked.

“Texas!” one of the participants shouted.

San Francisco has its Golden Gate. NYC has the Statue of Liberty. Texas has livestock and more swagger than you can fit in a ten-gallon hat. Eat your core out, Big Apple.

I explained to my audience that the topic I was about to cover had the potential to get a bit dry, and that I wanted to brainstorm with them about how to make it as interesting as possible.

I briefly reviewed my father’s love for fishing, and I brought up the idea of the hook.

“What would be the perfect hook?”

Whispering. More whispering

“Chocolate!” one of the participants proclaimed.

There is a particular chocolate here called “Tex”. It is basically like an oversized Kit Kat. There was a grocery store across the street where they were on special.

“Tex bars? It’s a deal.”

I divided the group into teams and asked them to choose team names.

They chose Team Texas vs. Team New York.

I kid you not.

I then explained that I would ask multiple quiz-type questions throughout my presentation. The team answering the most questions correctly would win Tex bars.

I started with a brief recap of the previous epidemiology lecture. I reminded them that nearly half of pregnant women in Swaziland are HIV positive.

“Do you remember the number?”

“42.6%!” one of the nurses said. Score 1-0, Team New York in the lead.

Boooo!

I reminded them that, without treatment, nearly half of HIV positive pregnant women pass the infection to their newborn child.


“What percentage?”

“About 40%!” Score 1-1.

I told them that HIV was retrovirus, meaning…

“It contains RNA!” 2-1

It is also a lentivirus, meaning…

“It is slow!” 2-2

“Exactly. This means that it lets its host live for long enough to infect others. As a
matter of fact, usually the infectious person has no idea that he or she is infected, for there are initially very few symptoms, and an individual can feel quite well while the virus slowly percolates, becoming stronger and stronger, like the coffee that awaits you as soon as we finish the lecture.”

I could hear the faint clicking of the tea-time percolator on the other side of the conference room door.

I continued to tell them how HIV thinks and acts. I told them how it enters cells, replicates, and then leaves to infect other cells. I told them how HIV destroys the CD4 cells that normally protect the human organism from infection.

They knew much of this. The score was 12 all.

I went into more and more detail and asked more difficult questions. When I ran out of powerpoint slides and difficult questions, the score was tied at 16-16.

I thanked them for being one of the more engaged, energetic audiences I had met (for indeed they were), and then assumed the more casual posture that one assumes to demonstrate that a lecture is finished.

“What about the chocolate?”

“But it was a tie.”

“Let’s have a tie-breaker!”

“Okay. A bonus question.”

I put up the photo of my family, and asked them to point out which one was my father.

They entire room exploded, with all participants pointing to the tall, wide-eyed man with a ten-gallon hat and the big grin.

“What is his name?”

“Chuck!” in unison.

His favorite lake and fish

“Lake Texas-Omaha! Striped sea bass!”

“Close enough.”

My grandfather’s name and profession?

“Dr. Ray! Pathologist!”

Still more or less a draw.

“We will just have to get enough for everybody to have one,” I said.

We adjourned for tea, coffee, Tex bars, and miniature tuna sandwiches.

I have been fishing with my father several hundred times. The last ocassion was just before moving to Africa. We left Eisenhower Marina when the sun was about a finger’s width above the western skyline, and we began to motor about in search of promising waters. The army of pied lures rattled in the three mega-tackle boxes at my feet, the water was glassy and reflected the late day’s light, similar in shimmer and color to coals beneath a dying fire. My father’s face wore an expression of determination, relaxation, and contentment. The horizon undulated as the boat hovered over the broad waves of the broadest stretch of the Red River, so named for the region’s crimson, iron-rich soil. The temperature was such that the moving air neither cooled nor warmed the skin as it passed.

There were no casts that evening. No lure left the boat, and no striped bass became fried Phelps-food. We just toured the spots where the fish might be, looking for splashes, birds, telling wind patterns. Finding none, my father and I spent the last hour of that day simply moving over glowing water at 35-40mph.

I have been fishing with my father several hundred times. No fishing trip has ever come close to that last one.

I bet it would have made my grandfather, Dr. Ray Phelps, proud to see his son and grandson that night, gliding over Lake Texoma, where he once lived.

Props to Africa - A situation comedy

The day before yesterday, it was my running shorts. One glance at me leaving work to jog home and the clinic nurses and translators burst into synchronous laughter.

Yesterday, it was my pronunciation of the SiSwati phrase “Sanibonani, S’Celile?” ("How are you, S’Celile?") Apparently my pronunciation needs some work.

I like being laughed at. It speaks volumes about who I appear to be in the eyes of others, and no ex-patriot is going to play a meaningful role in Africa or anywhere else for that matter unless he understands how silly he sometimes seems.

Being laughed at also assures me that those laughing are comfortable letting me in on the joke, the joke being an unwitting me. If a person is looking you in the eye while holding their sides as they shake with laughter, it bodes well for your working relationship.

At least this is what I tell myself.

Still the question remains: Why am I such an amusing spectacle here in Swaziland?

In the two instances above, I came up with the following: Regarding jogging, it must have to do with my willingness to running around in skimpy clothes for no particular reason in spite of the fact that I have a working automobile. (Combined, perhaps, with the blinding pallor of my sun-naïve legs.)

Regarding my blundering the local language, I attribute the laughter to my sloppy delivery of over-enunciated-but-still-mispronounced syllables coupled with the poorly-timed flicks of my untrained tongue in a feeble attempt to create the half-click-half-kissing noise that is woven into my colleague’s name—“S’Celile”. (Pronounced sss—kiss-like sound—eh—lee—lay.)

The kiss sound is actually less like a kiss and more like the sound that a wayward cowboy would make to get his well-trained horse to speed up without using his spurs.

You get the idea.

In a nutshell, Ryan in Swaziland seems analogous to one of those slightly outdated prop comedians (Gallagher, Carrot Top, and the like) who take something ordinary and use it out of context so that it is funny…or sort of funny…or simply annoying.

Of course, unlike yours truly, they do this intentionally and they receive remuneration for their efforts.

In my case, though I am ordinary by American standards, I am most certainly out-of-context here, and therefore my Swazi audience finds me funny or sort of funny or annoying from time to time.

Anyway, this is my working hypothesis. It is not a good or testable hypothesis, nor does it matter much either way.

Allow me to move on to a related topic that does matter.

The “developed world” has examined Africa for many years, and there has been little laughter. We observe from afar with the expectation of seeing darkness, disease, and despair, and so we see them.

Darkness, disease and despair make miserable punch lines.

Some observers do laugh at Africa. They seek opportunities to make derogatory, comparative statements emphasizing Africa’s deficiencies and then they chuckle sarcastically. Such sarcasm is not funny, and these chuckles are laced with ignorance and guilt, inspired by misplaced and heartless pride.

It makes me angry.

Let me tell you about Africa's darkness, disease, and despair from my vantage point.

The nights can get quite dark, darker still when the electricity goes out. (Most of Swaziland has no electricity to lose.) Having recently spent some time in darkness, I found that I prefer dim candlelight to that from a bleaching white bulb, and I have seldom seen brighter stars than those during a blackout.

There is much disease here, but there is also a growing understanding that these diseases can be treated. In all places, sickness can undermine a dignified life, and even diminish one’s will to live. Epidemics and fatalism are close traveling companions. In spite of this, Swaziland’s inhabitants love life, even when surrounded by or facing death. They want nothing more than to live long and be healthy, and I predict that they will have more and more opportunity to do both in the years ahead.

As for despair, it exists here, as it does everywhere. This is, after all, a country where a day’s work earns you an average of 2-3 dollars, necessities are often lacking, and luxuries are essentially absent. Still, I have yet to pass a family on the street and not be greeted. I have yet to shake a hand without it being coupled by a smile and a respectful sideways glance. I have yet to pay someone a compliment and not have it answered by a careful bow. The situation here is difficult, but the people respond with grace and resilience.

Within the context of the “developed world,” Africa may seem a dismal, desperate place. At least that is the story that is told. Hapless despair, I suppose, makes for a marketable human interest piece, and is certainly a sound if not cynical approach to fundraising.

I prefer to tell a different type of story, in which determined, benevolent people face adversity with endurance and a good sense of humor. These stories, I feel, should be the first ones told, for they are stories of hope.

Here is a working hypothesis for you, and I believe this one has been tested: Hope perpetuates itself, and hope in perpetuity has transformational power.

So, if you want to tell me a story about Africa, give me one where the protagonists laugh a lot, even if they are laughing at me.

Mountain oysters

The clinic kitchen is where we, the clinic staff, often have our morning tea and eat our lunch. It is a nice place to sit and get to know your co-workers better.

Last week, there were a couple of translators having pumpkin with their lunch.

Pumpkin flesh, for those who have not tried it, is very tasty, sort of yam-like in flavor and color, but less sweet and more meaty.

I explained to the two pumpkin-eaters that pumpkin was not part of a typical U.S. diet.

“Really?” they said, not quite in unison, with eyebrows raised.

Then I explained that we only ate the pumpkin seeds, baked and salted, and that we usually did this after carving out the pumpkin so that we can put a candle in it to make it look scary for our holiday where children dress up in costumes and ask for candy.

“I have seen Halloween in the movies,” one translator said.

I continued. “We do not eat the pumpkin flesh itself, unless baked into a sweet pie.”

“A sweet pie?”

Most pies here are savory, and none contain gourds, as far as I know.

“Do you eat grasshoppers?” one of the ladies asked in a thinly-veiled attempt to one-up sweet pumpkin pie.

“Never.”

“Me either, but they do in the country. Very good protein. We should include it in our nutrition counseling.”

Not to be outdone, I told them about the “turducken”.

“You eat a duck stuffed inside a turkey stuffed inside a chicken?”

“Not exactly in that order,” I said. I told them it was a nice treat for anyone who likes to eat meat. Swazi’s, in general, love meat, though it is expensive and often hard to get.

I told them it would probably work with ostrich and they should start an osturducken business.

“Do you eat caterpillars?”

I was not sure that caterpillars one-upped turducken, but I gave her the benefit of the doubt, especially when she reached into her bag and showed me what looked like pimpled fava beans.

On closer examination, I could see that they were indeed caterpillars. They smelled like caramel-coated almonds with a hint of summertime St. Augustine grass a few hours after mowing.

“I have never eaten caterpillars,” I responded.

"Me either, but they do in the country. This bag was given to me by a patient. Good protein. I am going to show the nutritionist."

And so the dialogue continued. We covered tripe, giblets, wild dove, oxtail, squirrel, snails, frogs, impala, sushi, warthog, chicken heart and other animal products. (Swazi’s, on the whole, love meat.) For you vegetarian readers, vanilla coke, sour mealy meal, and tofu were also mentioned.

The discussion had become a bit more competitive, with other Swazis joining in. The kitchen was getting crowded.

I was outnumbered and outwitted, but still determined to win. This determination was partially inspired by my innate competitive spirit, but there was more than pride at stake here.

You see, over the years, I have grown tired of “Westerners” tendency to sensationalize the dietary habits of the rest of the world, and I wanted to prove that our foods are at least as bizarre and grotesque as the next guy’s.

If we were keeping actual score, I would have been down by at least a few points, and time was running out. So, as my dining companions finished the last of their pumpkin, I threw the Hail Mary.

“Have you ever eaten a mountain oyster?” I asked.

“A mountain oyster? What is that?”

“It is the one with a shell that grows in the mud,” another said.

“Nope,” I said.

I thought briefly of an evening spent shucking and eating oysters directly out of Tomales Bay while camping with my family on the northern California coast. I did the same with my good friend Heath a month later, with a side of a couple Sierra Nevada beers.

Beers and oysters. Family and friends. How far away they sometimes seem.

“A mountain oyster is also called a calf fry.”

“A what?”

“A calf fry.”

“Fried calf?”

“Not exactly.” I paused until the anticipation grew more palpable, then told them a story about how these were my father’s favorite delicacy, if not a close second behind fresh oysters with Tabasco. (They do have Tabasco here, thank the heavens.) I told them how he fed mountain oysters to my in-laws without telling them what they were.

“Well, what are they?” “Yeah, what are oysters from the mountains?”

I told them that the mountains of Swaziland was home to many of these oysters.

The tension mounted.

Finally, I told them.

“Fried bull testicles?”

The group giggled, exchanging knowing glances.

“Dr. Ryan, Swazi’s prefer them roasted or stewed.”

Interception.

“Well, I’ll have to tell my dad that I am not as far from home as I thought.”

My nostalgia lifted slightly, though from now on I plan to carefully identify all roasted and stewed meats prior to consumption.

I learned this the hard way. I was in grade school. My father served me a fried morsel, and told me it was fish.

The Reed Dance

On September 10, I attended this historical and controvertial ceremony. I took several photos, available on the link at the bottom of this entry. The ones inserted here were chosen for their lack of "sensitive" content. I have attached a brief description of the event below.


Source: "The Umhlanga Or Reed Dance" By Richard M. Patricks, SNTC. July 2000. http://www.sntc.org.sz/cultural/swaziculture3.html


"During the ceremony, girls cut reeds and present them to the queen mother and then dance. It is done in late August or early September. Only childless, unmarried girls can take part.


The aims of the ceremony are to:
1. preserve giris' chastity
2. provide tribute labour for the Queen mother
3. produce solidarity by working together.


The royal family appoints a commoner maiden to be "induna" (captain) of the girls and she announces over the radio the dates of the ceremony. She will be an expert dancer and knowledgeable on royal protocol. One of the King's daughters will be her counterpart.


Day 1: The girls gather at the Queen Mothers royal village. Today this is at Ludzidzini (near Mbabane). They come in groups from the 200 or so chiefdoms and are registered for security. They are supervised by men, usually four, appointed by each chief. They sleep in the huts of relatives in the royal villages or in the classrooms of the four nearby schools.


Day 2: The girls are separated into two groups, the older (about 14 to 22 years) and the younger (about 8 to 13). In the afternoon, they march, in their local groups, to the reed-beds, with their supervisors. The older girls often go to Ntondozi (about 30 kilometres) while the younger girls usually go to Bhamsakhe near Malkerns (about 10 kilometres). If the older girls are sent to Mphisi Farm, government will provide lorries for their transport. The girls reach the vicinity of the reeds in darkness, and sleep in government-provided tents. Formerly the local people would have accommodated them in their homesteads.


Day 3: The girls cut their reeds, usually about to ten to twenty, using long knives. Each girl ties her reeds into one bundle. Nowadays they use strips of plastic bags for the tying, but those mindful of tradition will still cut grass and plait it into rope.



Day 4: In the afternoon the girls set off to return to the Queen Mothers village, carrying their bundles of reeds. Again they return at night. This is done "to show they travelled a long way".


Day 5: A day of rest where the girls make final preparations to their hair and dancing costumes.




Day 6: First day of dancing, from about 3 to 5 in the afternoon. The girls drop their reeds outside the Queen Mothers quarters. They move to the arena and dance keeping in their groups and each group singing different songs at the same time.


Day 7: Second and last day of dancing. The king will be present. (I attended this day.)


Day 8: King commands that a number of cattle (perhaps 20-25) be slaughtered for girls. They collect their pieces of meat and can go home.


Link for additional photos:
http://www1.snapfish.com/share/p=468241159114959548/l=210366615/g=5474961/otsc=SYE/otsi=SALB

So, here I am - An introduction

So, here I am.

The following paragraphs are from the desk of Ryan Phelps, a pediatrician from Denison, Texas who recently moved from San Francisco to southern Africa to help distribute HIV medicines. I am 31 years old. The words below are meant to set the stage for a series of stories that I plan to share over the year ahead as those stories unfold. So, without further ado, let me briefly set the stage. This ain’t The Lion King on Broadway. That’s Kenya through the eyes of Disney. This is Swaziland through the eyes of a small town Texan.

On August 18^th, 2006, I boarded a plane in Dallas for the first leg of my flight. My day-long layover in Frankfurt was a bit blurry, but I remember that I ate a frankfurter (“hot dog” in Frankfurt), a pretzel (no rock salt, no mustard, no carnival rides or homeruns), and a “Big Texan” McDonalds Burger (no comment). I also had a double espresso back at the airport but still nodded off while reading the paper. I awoke to the smell of newspaper ink (or whatever gives off that smell unique to printed news) and the sound of bustling passengers (who were maneuvering to take all of this drowsy transatlantic passenger’s bin space). I boarded the plane with my carry-ons hugging my lower legs like gangster concrete and arrived the next day in Johannesburg, where I loaded my things and pointed the nose of my vehicle eastward in the general direction of Swaziland.

Swaziland has the highest HIV prevalence in the world. Swaziland has a king, and he has many wives (in excess of a baker’s dozen). Swaziland has around a million Swazi’s living in it, and the landmass is approximately the size of New Jersey, though I wish I knew of another place about the size of New Jersey to avoid having to make this particular comparison. I make no apologies for the bakery analogy, however, for the king only marries once his chosen mate has a bun in the oven. What an immaculate concept.

The many-ovened king is a beloved man here, lording over a kingdom steeped in tradition, including culinary ones. He has inherited Swazi law and custom and the coveted duty of perpetuating it and (perhaps) benefiting from it. He does not cook. All Swazi men, king down to humblest pawn, make (and occasionally break) the rules around here. I say this without judgment, for I am ill-qualified (and otherwise reluctant) to charge or indict my hosts. It is very early spring here, and the weather is warming. When the chicks that hatch in a few weeks can be found within the small Styrofoam containers being sold at the local "Chicken Lickin", I will write a more seasoned editorial. Until then, I sincerely mean it when I say that I appreciate the kingdom of Swaziland granting me the opportunity to live and work here. In a world where few own a passport or ride a motorized vehicle, my doing both with a monarch’s blessing is a rare privilege, a trifecta of sorts.

My privileged voyage to Swaziland has two primary purposes: to help treat children (and adults) with HIV and teach other health care providers to do the same. I aim to do both to the best of my ability. As I do this, I plan to draft what one might call “field narratives” to share my experiences. I will do this with the best of this novice writer’s ability also. All efforts undertaken by amateurs (including amateur writers) must come with a disclaimer, and here is mine: I have never kept much of a diary nor written anything of import. For that matter, I have yet to even create an unimportant and yet entertaining read. Knowing as little as I do, however, I can assure you, the reader, that though I have only the most basic idea of why I am here, you will be among the first to know of my successes, failures, and lessons learned. Even if I am unable to accompany my observations with insight, I pledge to record my observations carefully, offering a sort of looking glass into this part of the world.

The near and distant future of Swaziland, including the small role I am to play within it, is uncertain. At present, the worst of the modern-day plagues surrounds me. It is not like previous plagues, for which death was the only option. This disease can be treated. Still, millions die. This is why this ill-qualified writer writes; I believe strongly in what we are doing here.

My faraway backdrop is Swaziland’s capital, Mbabane, a clean town of approximately 80,000 perched above a large valley and among small stony mountains. I do not know the type of rock, but they are a sandy-beige and their effect is most inviting. It is the type of terrain that looks good on the cover of magazines that sell high-tech, expensive outdoor gear. For this and other reasons, my impression of Mbabane is that it looks (abounding natural beauty) and feels (crisp, sunny early spring days and friendly people) like a place where one would not mind living. Of course, I am told that the honeymoon when changing continents and cultures can last six months, so my descriptors may change after I have bedding here for a longer spell.

Traditional Swazi village

I live in a large, comfortable house with a sheltered, suburban feel and sufficient bedding for any potential guests. Hot water and electricity—yes, usually. Central air—no. My yard has an avocado tree and is surrounded by “bluegum” trees and pines. The avocados fell to the ground and rotted just before my arrival. Darn. Within the nearby pines are dozens of pendulous, tear-shaped nests belonging to small weaver birds that I have yet to google and speciate (Swazi internet is glacial, and yes, the verb ‘google’ is now officially part of Webster’s). The weaver nests look a bit like avocadoes but are well beyond reach, firmly attached, and, as far as I can see, inedible.

I guess I will have to wait around a while for the free avocadoes. I need to cultivate an onion, tomato, and jalapeño patch so that I can make guacamole when that time comes. Of course, I cannot make margaritas without a lime tree and agave cactus plant. It seems as though I have a lot of gardening to do to minimize homesickness.

Though Tex-Mex is but a dream, Mbabane has similarities to Denison, Texas. At night, in my back yard, frogs croak and crickets chirp. Occasional woodpeckers peck. Cars are rarely heard.

Unfortunately, there is a very un-Texan, sickly rooster nearby that occasionally calls out to the local henhouse, though the call is more like a cough or wretch than a cock-a-doodle-doo. Actually, when he crows in the middle of the night, the sound closely resembles that a belch would make if one where being choked while belching. I hope that the hens share my opinion, for should this rooster father a dozen little belchers, my community’s charm (and similarity to rural Texas) would be in grave jeopardy.

My home does not resemble that of most Swazi homes, which are organized within a traditional rural patriarchic, patrilineal village. This ex-patriot will have to defer on the definitions of these anthropological categories, for I am not an anthropologist.

The streets of Mbabane are mostly paved (and mostly free from trash) as are the main highways heading west (to Johannesburg), south (to Durban and Capetown), and east (to Maputo). The town center is lively and equipped with shops selling the familiar (KFC, Woolworth’s, Shell) and the unfamiliar (specific examples require familiarity). All that one truly needs, and more, can be found in Mbabane.

I navigate my new town on the left side of the road in a car with its steering wheel on the right. I am allowed to take a left on a red light. All of this frightens me, so I bought a mountain bike for my commute to work (1.5mi). Besides, there are all of those alluring mountains on all sides, so I had to gear up.

The clinic where I work is called the Baylor College of Medicine - Bristol-Myers Squibb Children’s Clinical Centre of Excellence, Swaziland, or “COE” for short. It is a spacious, newly-constructed building where children and parents can receive HIV testing and treatment. It walls are adorned with Swazi handicrafts, cultural garb, and various local photos. One hanging reed mat has woven into it the words, “Feel at home”, and it is indeed a cozy, welcoming place. Within these walls, a small number (in the hundreds) of children and family members receive medicines that have the potential to allow them to grow old though infected with HIV. My job is to try to increase this number (with a goal of >1,000 patients on antiretroviral treatment within a year) and expand pediatric HIV services in other parts of the country.

A child dies of HIV/AIDS every 60 seconds. This is disease that destroys children, families, and continents. Worse still, it destroys hope. It is a disease that leaves me feeling under-qualified despite spending my teens and twenties pursuing qualifications. Though HIV is an intimidating virus, excellent treatment exists. A very small proportion of Africans with HIV receive this treatment.

There is a catchy saying here. It goes something like: “Let’s put one and one together and see if we get two.” I have no delusions that I am going to save the world, but putting effective, available medicines and dying human beings together adds up. Failing to do so does not. So, here I am.