Reparations in La Mancha - A patient encounter

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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.

What am I up to? (21 May- 25 May)

Baylor Swaziland is funded by UNICEF to organize and complete periodic regional trainings. The first training of this fiscal quarter was last week. The teachers were a handful of Baylor staff and myself. The pupils were twenty community nurses. Here is an overview.

MONDAY: Lectures included: epidemiology of HIV in Swaziland, the pathophysiology of HIV, the diagnosis of HIV, and primary care of the HIV+ child. Highlights included:
- The opening song; though we started about three hours late, the group immediately distinguished themselves as a pitch-perfect choral ensemble, despite the fact that it was the first time they had ever been in the same room, much less harmonized.
- The five minute video of the HIV lifecycle: It is an animated production that makes HIV look like a spherical spaceship and uses sci-fi images to teach how HIV multiplies. Imagine what Steven Spielberg would see if he looked into an electronic microscope.

TUESDAY: Lectures included: ARVs, TB, opportunistic infections, and PMTCT. Highlights included:
- The OI case identification contest. For the opportunistic infection lecture, I presented a series of cases. The participants, who were divided into teams, were tasked with identifying the OI in a format similar to final jeopardy. In the end, a team who had named themselves “the ducks” narrowly defeated “Wonderboy’s team”. Other team names included “the women of excellence”, “the Zambians”, “the elephants” and the ever-popular, internationally renowned “A team”.

WEDNESDAY: Lectures included: ARVs, TB, opportunistic infections, nutritional management, and infant feeding. The repeats are due to the scheduled rotation of half of the group though the Baylor Clinic on both Tuesday and Wednesday mornings. Highlights included:
- The infant feeding workshop, ran by Eileen, which allowed the attendees to rotate through stations and perform various tasks, including growth charting, dietary advising, lactation counseling, etc.
- The shining feedback from the half-day clinic visits. Comments included:
o “It was very very touching to me. When the mother entered you could see depression and all of the things she was going through. The explanation she got [at the clinic,] the advice, it was good.”
o "That the pharmacists sit down with everybody and not that song that we usually hear. At times, when you see the queue you just say two times a day of this, two of that. It is not the best way. At Baylor, the way they counsel and label the medicine, it is good.”
o “Every thing was in order.”
o “I liked the way they kept records, on…what do you call that thing?” Another nurse replies, “Computer?” “Yes! The computer! We should use them too.”

THURSDAY: Lectures: counseling about HIV, adherence to ARVs. Highlights:
- Nosipho, the social worker who gave these lectures, told a story about a HIV+ man who, not knowing his status, entered a Swazi testing center with a gun, put it down on the table in the counselor’s office, stood blocking the door, and said “Okay, I would like my results now.” “What would you do?” she then asked the group. A lively discussion followed. Answers included:
o “Tell him he is negative.”
o “Tell the truth.”
o “Ask him to please come back later.”
o “Quickly grab the gun.”

FRIDAY: Lectures: Case presentations by participants illustrating what they learned. Highlights:
- Having promised to lead the morning song if the group maintained punctuality, I delivered on that promise. In an attempt to cover for me, the chorus of nurses sang backup even more beautifully than they had in days prior.
- The discussion about the “way forward” after the workshop was heartening, with participants expressing a desire to return to their respective clinics and institute several new practices, including:
o Improving adherence numbers and follow-up
o “Need to probe more regarding HIV status”
o Renewed focus on PMTCT
o Improving the physical exam for recognizing HIV cases
o To start ARVs early, before the child is too sick
o More diagnostic attention to improve and guide care
o Improving HIV staging
o When a patient is on ARVs, to “recognize the drugs, review them, and advise.”
o To share ideas and lessons learned with other colleagues after returning from the workshop.

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Last week was a good week. Except for the tripe, that is. (More on this soon.)

This week, I am back to seeing patients. (More on this soon as well.)

What am I up to? (21 November-25 November)

The week has been one of those “steady-as-she-goes” kind of weeks. Similar to last week, I worked in our outpatient clinic (see entries below for more specifics) from Monday through Thursday, and yesterday we had general staff and MD meetings (see below for abridged meeting minutes).

In actuality, I have been doing a lot of behind-the-scenes work in preparation for this weekend’s Thanksgiving dinner, but to no avail.

On that note, if you know how to procure an ostrich in Swaziland, contact me immediately. (Alive or dead is fine.)

Apparently they used to run around wild here, but I cannot find one anywhere, though their painted, preserved eggs clutter every curio shop in Sub-Saharan Africa.

I tell you, fellow Americans (and other highly-valued blog readers), I am shocked at the absence of a Thanksgiving ostrich market in these parts. Shocked.

There are a few big, flightless birds running around the Mlilane Game Reserve a few kilometers from here, but I have zero interest in having my Thanksgiving meal in a Swazi prison.

Less than zero.

It would be a very un-American experience.

What I would not do (besides Swazi jail) to carve and eat ostrich before Thanksgiving weekend ends!

I would settle for guinea fowl (turkey-like, as pictured above) if they were not so gamy and tough.

Oh well, we may have to settle for a gobbler.

Now that I think about it, since there is no football on TV (the pigskin variety, I mean), we might as well eat gobbler to Americanize the experience a bit.

The rumor is that there will be apple pie.

This thankful pilgrim certainly hopes so.

What am I up to? (5 Nov – 12)

In the interest of sharing a few more of the day-to-day details of my life here in Swaziland (as requested by a few of you), I offer to you this update:

The past week began and ended with travel. I returned from Malawi on Monday afternoon and saw patients in the clinic--i.e. the Baylor Center of Excellence (COE)--Tuesday through Thursday.

My three clinic days were typical clinic days. I arrived at the COE at 7:30 or so, waved as I walked in through the waiting room, and headed to the kitchen to prepare a cup of instant coffee. This ordinary entrance is followed by a “quick” check of the emails I received while sleeping, not-so-"quick" connection speed permitting.

[As foolish as it might sound, I still have conceptual difficulties with the undeniable fact that my today is somebody else’s yesterday, and that when I arrive to work on Tuesday, Monday is simultaneously out there somewhere. In any case, I tend to receive email messages in the middle of the night, and check them when the senders are just entering REM.]

The instant coffee helps me clear this up inside my head, and, once situated in time, I grab the first patient chart, usually around 8:00. Some time between 9:30 and 11:00 I happen to pick up the chart of an English- or Portuguese-speaking patient and the SiSwati translator goes to tea. A mid-morning break is a foreign concept to many, but I can assure you that if it is one’s job to accurately and tactfully translate the things that come out of my mouth, she deserves tea.

Patients continue to come and go throughout the morning. Some are very sick, and some are not. All, with rare exception, are HIV positive. (Those that are HIV negative are able to see a physician on the day they are screened, but are then referred to the local general pediatrics clinic, as it is our mandate to care for HIV-infected children and their families.)

On a typical day, lunch comes at around 1pm and ends shortly thereafter, when I pick up the next chart.

An average day’s patient volume will be around 12-16 patients per physician (similar to subspecialty clinics in the US).

Patients usually come in groups of 2, but some are seen individually, and families of three or four not uncommon. Two-thirds to three-fourths of the patients I see are children, and the rest are adults. There is always an available internist or family practitioner if I find myself inundated by complaints of lower back pain, hypertension, etc, and need to consult an old-person-doc.

Approximately half of the patients seen are on antiretroviral medications. The other half are being monitored and treated until their CD4 counts drop to the range where ARVs are indicated. Most patients come in for scheduled visits (routine labs, adherence checks, clinical follow-up, nutrition/social worker counseling, med refills, etc), but a handful drop in because they are ill and need to be seen without an appointment.

On a typical week, I admit one (maybe two) children to the hospital. This process is well-known to any outpatient physician, but here in Mbabane there is one significant difference—the hospital often has fewer resources than the COE. To minimize the effect of this disparity, we do as much as possible for the child before the child is transferred, and we communicate directly with the doctors receiving the patient at Mbabane Government Hospital. To ensure adequate follow-up and to help address some of the hospital’s unmet needs, we also assign at least one Baylor Aids Corps physician to round during the week at “MGH”. (I will be there next week, so stay tuned for more on this.)

Patient care usually wraps up between 3:30 and 4pm, at which time we typically have informal meetings, review labs, or continue working on other projects (PMTCT, improving clinical protocols, nutrition program development, training preparation, etc.)

This, in summary, is a typical clinic day. I hope this description answers more questions than it generates. If not, let me know and I will elaborate further.

Friday was filled, as usual, with administrative and academic meetings. We discussed TB protocols, a recent patient death and its most likely causes, the Malawi COE network meeting, and more.

As I stated, last week ended with travel. A mere 4 hours southeast of Mbabane, there is a beautiful bay (called Sodwana) that is also a South African national park. They say that the diving there is second only to the Great Barrier Reef. This has to do with the diversity of fish and coral, the visibility, and other underwater details. For such details, ask one of those people with that rectangular red and white scuba sticker on their back windshield. They will know.

I went to simply spend a day on the beach, and I did just that. We left for the beach Saturday at 6am, and came back early Sunday.

Sunday evening, I read some of Sachs's “The End of Poverty” before closing my eyes, jealous that everybody in Texas was just sitting down to Sunday brunch (a tradition I would trade for morning tea any day), and hopeful that the book on my nightstand was correct and that the world was indeed on track to change for the better.

What am I up to? (30 October – 5 November)

Some of you have asked me to post intermittent "informational" blogs about my day-to-day, and so I begin with this past week, which I spent outside of the kingdom of Swaziland in the country known as "the warm heart of Africa"--Malawi.

Malawi, as you will see below, is a beautiful country, and this past week happened to be the site of the biannual Baylor International Pediatric Aids Initiative (BIPAI) network meeting. The conference and associated gatherings took place Monday-Thursday, and included representatives from all of the BIPAI-affiliated sites (Botswana, Burkina Faso, Lesotho, Malawi, Swaziland, Uganda, Romania, and others). I was lucky enough to participate.

This is a photo of Dr. Kline during the opening session. He is reminding us why we are here.



Note that Africa is fiery-red. If you have access to an alarm bell, please ring it.

The network meeting, in short, is a time to share ideas, innovations, and clinical cases to ensure a coordinated, proactive and united front between the many centers.

The meeting corresponded to the opening of the Baylor Center of Excellence in Malawi, the construction and operation of which is being largely funded by the Abbot Fund and UNICEF. It is a beautiful, functional building (see photo below), and it will be the home base from which the Baylor Aids Corps physicians in Malawi will care for HIV positive children and families, broaden similar services to health centers nationwide, and coordinate HIV training and prevention strategies.


Banda, Republic of Malawi Minister of Foreign Affairs, left, and Reeta Roy, Abbott Laboratories Divisional Vice President for Global Citizenship and Policy, unveil a plaque commemorating the event.

If you want more details on the meeting or the opening, check out http://bayloraids.org/programs/malawi/ or simply email yours truly.