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

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!

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"

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

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.

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

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"

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"

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

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

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)

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.

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

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

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

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.

Swazi children.

May we make the most of it.

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

"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

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

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

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

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)

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

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"

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

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