Swaziland

Dave and Tessa report from Mbabane

Ghana

July 28th, 2007 by Dave

(These are all journal entries that I wrote earlier on paper and am now just copying down in my blog. They are all just tiny snippets as I haven’t been able to find any decently large chunks of time just to sit down and write. It’s kind of a helter-skelter mish-mash.)

–Three kids, somewhere in the range of seven to ten years old are sitting next to me as I write this now. I’m sitting outside on the back porch of my dormitory at the Margaret Marquat Memorial Hospital where I’ll be working for three weeks as a volunteer. I had been sitting for only about ten seconds when they came up, smiled big (I, of course, smiled back equally big) and asked “Are you writing?” “Yes, I’m writing in my journal,” I responded. Then, they continued to stand next to me, still smiling and very curiously watched what I am doing. Two of them even decided to sit down next to me and are still just watching without saying a word.

Just now, it appears as though they have had their fill. They say “Goodbye” very enthusiastically and sincerely and then wander slowly away. (Okay, that sounds a bit hokey to say they said goodbye sincerely, but honestly they did. It was as though they were thanking me, as if they had received a great honor by just being allowed to sit by and watch me write.)

–I’m sitting now at a desk in the Kpando City Assembly Hall. A large Ghanaian man is yelling at the top of his voice at me and the group of pink-shirted nurses-in-training that I’m sitting here with. I can’t pick out anything he is saying though; the rain outside is coming down so hard that he’s basically muted. He is sweating heavily. So are the rest of us, for that matter. It is sweltering hot here, as it is basically every day. Sweat is dripping down my chin and forehead. I try to keep dry by wiping it off with a hand towel, but it’s a pretty pointless endeavor as, no matter what I do, the sweat continues to pour.

I’m hoping that the rain will stop soon, as it is foiling our plans for the day. Two nurses, Prince and Godwin, have invited me to go out with them from house to house to educate about sanitation and hygiene. It is part of their training as nurses–each nurse in the program must spend two months working in this area. I’m very excited to go with them. I want to see what they teach and how, and I’d like to help them by also teaching the people about what I know about these topics from my work in Swaziland.

–The rain never did stop. It went on all day. Apparently, rain like that is not at all uncommon here.

I did get the chance to go out with them the next day though. It was really great. We went from house to house looking in water barrels, inspecting room drainage systems, checking out out-houses and where wastewater was being dumped. It turns out that Ghanaians are doing quite well in the cleanliness arena. Most had fairly clean houses and clean water. The biggest problem we encountered was that most people were not covering their water barrels with lids, thus allowing mosquitoes to get in and lay their eggs in the water. Mosquito eggs and what they later grow into, larvae (which we saw a great deal of), are obviously not a good thing to take in with your drinking water. And providing the mosquitoes a nice place for them to raise a family is obviously not the best way to prevent the huge malaria problem Ghana is facing. So we told them to buy lids. And, apparently, here in Ghana what these nurses say, at least when it comes to hygiene, goes.  Improper hygiene is actually a criminal offense here, and if the situation isn’t fixed when the nurses check again, they are free to press charges.

We also told people to cover their rain gutters (their source of water) with nets to keep out unwanted bugs and debris, to put their trash in a trash can rather than just on the ground, and to weed their yards. This last piece of advice seemed a little bit strange. I mean, sure, a weed-free yard is nice, but isn’t it a little much to require it by law? So, I asked Prince about it. He explained that unweeded yards are the perfect place for snakes and scorpions to hide. And man, does Ghana have a LOT of snakes; their are pythons, puff adders, Gabon vipers, spitting cobras, boomslangs, mole snakes and black mambas. (Yesterday, I was helping out in the surgical ward and there was a patient who had been bitten by a snake in the forest on her way to get water. She decided to try traditional medicine for about a week, but then after realizing it was doing no good, came in to the hospital. The bite was pretty ghastly-looking. A 2-inch deep cavernous hole in her leg. Theresa, the head nurse, who was in charge of cleaning wound had to put an unbelievable amount of gauze into the wound before it was filled.) I find it very reassuring to know that the citizens of Kpando are doing what they can to keep these little critters out of town.

–”Okay. Come on Junior.” I say to the four-year-old boy who has a feeling-terribly-left-out expression on his face. He smiles and grabs hold of my hand and clambers up into my arms. It’s actually impressive that he was able to find his way up as my arms were already at what I had thought to be maximum occupancy with 2-year-old Nancy in my left arm and 1-year-old (or thereabouts) Gabriel in my right.

The orphanage isn’t a very big place–just a couple of little concrete buildings with enough space to squeeze-in the thirteen orphans that live here. It is fairly new, started just about a year ago by a Ghanaian man named Richard and a woman named Joy from Spokane, Washington. I haven’t met Joy, as she has returned home, but I have talked to Richard quite a bit and he is a very kind and intelligent man, and it is easy to see that he loves these kids very much.

Nabid, Ann, Lindsay and I arrive at the orphanage at 2:00 (when the kids return from school) and then stay until about 5:00 every day. We always have a wonderful time. Nabid plays basketball with the older ones, while Ann is mostly into working with a few at a time on reading and writing. I sometimes teach them about drawing, which they are quite fascinated with, but, honestly, I spend the vast majority of my time just carrying them around (usually three at a time) and giving out hugs. I can tell that they really need it as they can never, ever get enough.

I’m glad to do all that I can to cheer up their lives. However, I’m worried that this is not enough.

The reason all of these kids are orphans is that their parents died of AIDS. Therefore, it is extremely likely that many or most of these children are also HIV+. We don’t know for sure, but we think that only a very few are on any sort of ARV treatment.

It is very depressing to know that these orphans who we all love so much might not be here in a few years.

We are all thinking very hard about how we can help them.

Tessa’s Final Blog

July 19th, 2007 by Tessa

My last week in Swaziland is drawing to a close. Tomorrow I’m off to Cape Town, and 10 days later, I head back to the States! As excited as I am to explore South Africa, I’m almost more excited to return home. In addition to finishing up my various projects, I’ve spent quite a bit of time this week finalizing details for my return home (ie: apartment, job, insurance…) It is so weird to think I won’t be living with my parents or in a dorm. For the first time in my life, I’ll be supporting myself. I feel like it is even more of a transition—more of unknown territory—than going and working in Africa for the first time. It certainly is more permanent.

Anyway, that is what has occupied my mind as I started packing and saying goodbye to everyone. As sad as I am to leave, I’m also eagerly anticipating the next new experience. Coming to work here in Swaziland was the perfect thing to do after graduation. I certainly gained some perspective on health inequalities and on problems in developing world healthcare systems. But I also gained a great deal of perspective within my own life. I had so much freedom here to do what I wanted with the projects. Nothing was planned before I got here, so I got to do all the planning. And then, I was responsible for realizing the plans. The same goes for my life: I get to choose where to go from here, and I am the one who must make things happen. I definitely plan on going back to graduate school eventually to get my MPH, but it isn’t like before, when I knew that the next x number of years, I’d be in school regardless of other decisions I made in my life.

Working here also made me realize how important access to and quality of healthcare are, how difficult it can be to implement a seemingly simple project, and how there are always going to be unforeseen challenges no matter how well you plan, so it is important to be adaptable and constantly aware of what is going on. I have no idea what exactly I will be doing in 5, 10, or 25 years from now, but after working here, I am certain that whatever it is, it will be somehow related to inequalities in healthcare. There are so many resources and so much wealth in the world, and so much of it (even when it is intended to go to the sick and the poor) never makes it to those who most need it.

For example, a few months ago, there hundreds of packages of plumpy-nut sent to Swaziland. Plumpy-nut is a food supplement that is used to treat malnourished children on an outpatient basis, and it has been very successful in other countries that have started using it. It is supported and promoted by many organizations, including the World Health Organization. The doctors at the clinic were elated to hear the good news until the ministry of health declared that they needed their own specialists to look at plumpy-nut before it could be distributed. Knowing the snail-pace at which everything happens here, the elation was quickly replaced with extreme frustration. So, the plumy-nut sat here in Swaziland for months, only a few hundred kilometers from the starving, dying children, and there was nothing the doctors could do about it. Luckily a conference of sorts was held here with many international organizations, and one of their first questions was, “Why doesn’t Swaziland get plumy-nut here?!” Once they were held accountable for their behavior, the ministry took action, and now things are looking up. The frustrating thing is that there usually isn’t anyone holding them accountable, and in the future, a similar situation could occur again.

So I guess I will leave it at that. This internship has been eye-opening, to say the least. As much sadness and pain and needless suffering as I have encountered here, I have also seen just as many successes in the healthcare community, and I leave here feeling both hopeful and determined to stay an active member of this global community that strives to transcend political, social, and economic boundaries in an attempt to relieve the needless suffering that exists in the world.

Photos from Madagascar

July 15th, 2007 by Dave

Here are some photos from my trip to Madagascar:

My sister, talking to one of her friends.

Greggory’s neighbors–they changed into their very nicest clothes for this picture.  The littlest is holding her barbie (obviously her most prized possession).

Greggory and I made a visit to the home of the woman in the purple jacket.  The whole neighborhood crowded into the hut to see us (and when I say ’crowded’, I mean it–the hut was about 6′ by 6′ and there were about 15 of us).   On leaving they presented us with a huge bunch of bananas as a gift.  We tried to refuse, but of course they wouldn’t let us. 

Greggers and I in the clinic where she does work with women’s sexual health.  She helps the nurses with checking in patients and gives lectures about pregnancy, nutrition and sexually transmitted diseases and I’m sure much more.   Of course, she does all of this in perfect Malagasy. 

Tessa14: New Adherence Project and Hlane Park

July 12th, 2007 by Tessa

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Now that the new volunteers have taken over most of the WFP duties, I’ve been free to work on the new adherence project with Tina. Some background info about outreach… Baylor sends doctors to Good Shepherd roll-out clinics. These are clinics that are located in rural villages and treat mild ailments. But once a month, Good Shepherd (the hospital in the Lobamba region of
Swaziland) sends nurses to distribute to the HIV patients there. The Baylor doctors accompany them to see the patients, assess their health, and assess their drug regimen.

Good Shepherd uses a certain form to record the adherence of each patient. It basically has a place for counting the pills and then a place for a general assessment, but the adherence percentage is never calculated. Also, no recommendations concerning the adherence level are made. Tina gave me a new form to edit and test out in the field. This form makes it easy to calculate the adherence percent and make an appropriate recommendation (ie: continue ART, see an adherence councilor, refer to doctor, put in “high risk adherence failure” group, etc.)

Before I went to the outreach clinics, I edited the sheet to incorporate the system they use now and to make it visually resemble the form they use now. I figured the fewer changes they had to make, the more likely they would be to change. The first day we tried it out was Tuesday. Tina explained to the Good Shepherd adherence councilors what I was doing. One of them I’d met before and was happy to help me out, but the other one was initially very resistant. So I spent the first day filling the sheets out myself along side of them as they filled out their sheet. This gave me a chance to get to know the new councilor better. Also at the end of the day, they looked at it with me and gave me input about what they thought worked well and what needed to be changed.

Today, only one of the councilors was there. She was much more receptive and friendly today, and she actually had to use the forms for the last 10 or so patients since she ran out of her own forms. That gave her a chance to actually use and see what she thought about the new adherence sheet. Once she got the percentage calculations down, she seemed very pleased and asked for extra copies to take back with her to the hospital.

One other change, which I think will be much more difficult to make, is to get her to ask the patients why they took so few or so many extra pills. Sometimes—depending on her mood and on the patient—she just filled out the form and said nothing to the patient, even if their adherence was horrible. Thus, the patient had no idea that he/she is doing anything wrong. Having said that, she was also much better at counseling (more like scolding) them than the other councilor I met at the Vuvulane clinic.

Anyway, it’s turned out to be a very interesting project, and I’ve gotten to see much more of
Swaziland during the drives to and from the clinics. This past weekend was pretty fun as well. I went with David (not Dave Dallas but another visiting scholar) to
Hlane
Game
Park. It turned out to be quite the adventure when our cab driver took the wrong turn and we ended up driving on a bumpy dirt road through a huge sugarcane plantation, by an ominous looking factory, around the entire game park, and eventually reaching the entrance from the other direction. Luckily the sunset safari was running late, and we made it just in time. Our luck increased exponentially over the next two hours as we saw almost every animal they have in the park (we didn’t see cheetahs or leopards) which included some giraffes, elephants, rhinos, and lots of lions.

So I’m in Madagascar . . . No, seriously, I’m in Madagascar.

July 6th, 2007 by Dave

This morning I woke up in a tiny bed that I was sharing with my sister in the smallest hotel room I’ve ever been in. Greggory woke up first and took a shower and let me keep on snoozing for a bit, and then, while I took my shower (the shower was quite funny–you had to actually pick up the shower head and hold it above you to use it), she went down to a shop across the street to buy us some coffee. Gregg returned with the coffee a bit later and apparently the shop didn’t do take away quite like we’re used to–they sent her with the actual china cups and coffee pot as well as the cream and sugar pots. But it was quite nice and the coffee was delicious!

Then, we wandered around the city (Antananarivo, the capital city, which I think has far too many syllables). We peeked (yes, Mom I’m spelling ‘peeked’ correctly this time) into a cute little craft shop and bought a granadilla and the most delicious mandarin on the street. Then, we went to a French café and breakfasted on quiche, dainty pastries and hot chocolate. After that, we went to a really great outdoor market. I bought a beautiful alligator-skin belt for a ridiculously low cost (about 3 bucks) a nice bag of saffron, also for far too little money, and some beautiful pieces of jasper that Greggs and I bought and which we hope to have made into necklaces as presents for some of our friends.

Later, I visited her Peace Corps office and met a few of the members that were in the city. (All of them had a certain air of coolness that you must just get automatically from being a part of a program like this).

Right now Greggory and I are hanging out for a bit at an internet cafe before a big house-warming potluck for an ex-Peace Corps volunteer.

I would write more, but it’s pretty difficult to type on this keyboard. Perhaps I’ll post some photos when I get back to Swaz.

Tomorrow, I’m going to be making the six hour bus ride to Greggory’s site (the town she works in), Tanambe. About 18,000 people live there. They have electricity, but no running water. I can’t wait to see it so that I can really get a feel for what Gregg’s life has been like here for the past year and will be like for another year after this. I think it will be very helpful for me to see the way she’s living and how she handles that when I arrive in Ghana two weeks from now and will be living in a situation that is very similar to hers. (By the way, try not to judge my grammar, punctuation or writing style too harshly as I am mostly focusing on just trying to press hard enough to make this impossible keyboard work for me.)

Oh, by the way, it is so wonderful to hear Greggory speak in Malagasy (the local language). She speaks so naturally and is perfectly at ease interacting with the locals. I wish so much that I could do that–with any language! And speaking of language, Malagasy has some interesting quirks to it: in order to say “walk around” you simply say the word for “stand” two times. So when you are walking around in Madagascar, you are standing standing. Likewise, if you want to sit around, you must do some sit-sitting.

I think we’ll be heading off now to pick up a few beers to take to the potluck along with the homemade bread Gregg’s friend Sean made. (I think it’s so cool that he makes his own bread. I’ve decided right now that my next goal is to learn how to do that myself and start doing it all the time.)

Tessa13: Peace Corps and Rice visits

July 5th, 2007 by Tessa

Monday, July 2 to Wednesday, July 4

            I got up around the same time as I usually do for clinic (6:45-ish) to shower and finish packing for my long awaited visit to a Peace Corps volunteer’s site. Carrie had suggested I stay with a volunteer soon as I got here, but once WFP stuff started, I didn’t have any time to escape the clinic. We both thought it would be a good opportunity to see where the COE’s patients come from—not just physically, but culturally, emotionally, etc…Like, what kind of customs and beliefs exist in their communities? How are decisions made? What is the family environment like? How are orphans and abandoned children cared for? What is the system for governing? And also, this would give me an opportunity to talk with someone whose work and goals were similar to mine but who had been here much longer and worked on many more projects.

            Carrie gave me a volunteer’s number a couple weeks ago, and I had called her and set up a time to come. Tandi (that’s the volunteer’s Seswati name) and I met downtown by an internet café. She was very nice and happy to answer all of my questions. In what ended up being a very rushed morning (there had been some confusion with the new WFP system, and Dave called me to the clinic mid-shower) I hadn’t managed to squeeze in breakfast, so we sat down for omelets and coffee before heading out to her homestead. I was certainly glad for her company. I’d been on combies before (the vans used for public transport here), but only for short trips between the clinic and
Mbabane. Finding my way from Mbabane to Manzini, switching to another combie, riding from Manzini to Siphoneni, transferring to yet another combie, and riding out to her village (name was hard to pronounce, and now I’ve forgotten it completely) would’ve been quite an adventure (possibly an unsuccessful one).

            When we got off the last combie, we walked by a row of gogos (old women selling fruit or other items on the side of the road) and she greeted all of them with “Sanibonani” (the “hello” you use to address a group of people). A chorus of “Yebo”s echoed back, and the exchange continued for a minute. Everyone we passed, Tandi greeted and waved to. In that particular community, they used a two hand wave, which proved difficult since we were both carrying quite a bit of stuff. Discovering I had no Seswati name, Tandi enlisted the help of the gogos in naming me. I am now officially Zandile Dlamini. “Zandile” means “too many girls,” and Dlamini is the most common last name in
Swaziland. I’d say about 40% of our COE patients are Dlamini’s.

            We hiked for about 20 minutes to reach the homestead where she had been living for almost a year. The paths were dirt trails randomly winding and crisscrossing through brush and occasionally along pastures and homesteads. It reminded me quite a bit of the landscape and random layout of the community I lived in 5 years ago in
Nicaragua.

            At her home, I met her gogo (literally translate as “grandmother”) and the children who lived there. Her babe (father of the house) wasn’t home. In fact, he rarely is there, she said. Two of his three wives reside at that particular homestead, but neither was there at the time. One was shucking corn on the other side of the nearby mountain, and I’m not sure where the other one was. The one shucking was Tandi’s “mage” (mother…pronounced ma-ge with a soft g sound), and I got to meet her later. She was very well educated and easy to talk to. In fact, she had met her husband when they were both studying at a university in the
UK. At that time he already had two wives back in
Swaziland. She had hosted Peace Corps volunteers several times before and seemed like a very good host mom. She kept trying to make Tandi stop translating. (She thought I was another pc volunteer and thought I should know the language by now.)

            She said all the children there were her own, but Tandi told me later that in fact, they were all children of her husband, but none actually belonged to her. They were the children of all of his girlfriends. (Keep in mind; this is a completely normal arrangement for a family. Other than the fact that they were wealthy for a rural Swazi family, this was very representative of many of the homesteads all over
Swaziland. A homestead is basically a collection of homes that belong to one extended family—a gogo, a babe, several mages, and many children).

            Anyway, after I met the gogo (and before I met the mage) Tandi took me over to the hospital and VCT (voluntary counseling and testing facility) to see what they were like. It looked much like the Vuvulane clinic except bigger and cleaner (still nothing close to the COE standards). We talked to the VCT employees for a bit. They basically serve as a site where community members can come in and get tested for HIV. If they test positive, there are support groups and counseling available. Also, if they’ve been diagnosed and prescribed ART, they can pick up the meds there. One nice thing about this particular VCT was the fact that there was a woman who worked there whose sole responsibility was to deal with adherence. She was Swazi, and I believe she actually grew up there or nearby. She had obtained a grant for her project and was now trying to improve adherence in the community. Unfortunately, she had left for the day, so I didn’t get to speak with her.

            On the way back to the homestead, Tandi told me more about her experiences living in
Swaziland. She said adjusting to the culture wasn’t too difficult. She didn’t really get homesick, and the community welcomed her. Apparently the last volunteer was kind of angry. Whenever Tandi had events, people would always come up to her afterwards and say, “Thank you for not yelling at me, Sisi.” (Sisi means sister and is the word everyone uses to address a young woman who isn’t married). Evidently, the last volunteer had been a yeller. The one thing Tandi said was most difficult to adjust to was the number of deaths. Every week, there are about three vigils to mourn the deceased. They last all night and end at about 7 am with a funeral.

            Tandi also told me about the political structure of the community. Basically, there is one chief for each chiefdom (collection of homesteads living in an area together). Hers had about 500 homesteads but oddly, no chief. Theirs had died 2 years ago, and the king still hadn’t appointed a new one. Usually he chooses one of the late chief’s sons (whomever is most in favor of the king). No one is sure why he hadn’t chosen one yet, but some suspected that the dead chief’s advisor (who was ruling temporarily) was delaying the process. Tandi was skeptical. She said that things just take awhile in
Swaziland (which is definitely something I’ve heard from a lot of the people I’ve met here). Almost everyone in the rural communities respects their chief and the king greatly. They don’t question or discuss politics at all. Only in the cities, where there are more educated people, politics are a little more contentious.

            As we passed by the king’s corral, she told me about “tega,” another part of the traditional Swazi life. When a woman is sleeping over at her boyfriend’s house, a bunch of people will come over and “catch” her in the act. They yell out something to the effect of “Come out! We’ve tega-ed you!!” They then curse at her and chase her to the king’s corral and throw her on the ground. If she isn’t crying at that point, they will beat her until she is crying. Now, the whole point of this ceremony is to get the man and woman to marry each other. If she doesn’t want to marry the man, she has to run to a river (this part I’m not sure if I remember correctly). If she makes it there without being caught, she doesn’t have to marry him. Otherwise, she stays in the corral until she cries. How long she lasts before crying is actually a source of pride for many women. It is supposed to represents how much they love their husband. Tandi told me that one mage she met told her proudly, “I didn’t cry and didn’t cry. So they had to cut me.”

Later, I asked Sipho, one of the Swazi guys at the clinic about it. He said he didn’t really like the custom, mostly because of the implications for the women. He also said most people in the city don’t tega, but if they want to do it, they can go out to their parental homesteads and do it out there. The alternative is a civil wedding. If you are married that way, you are only allowed one wife, but then that woman relinquishes her individual rights and becomes essentially a minor under the control of her husband. For this reason, many women go to
South Africa to get married. When I asked Sipho what happened if a woman never slept over at her boyfriend’s house. He said that she had to in order to tega, and she had to tega in order to marry. He also said, the women don’t really have a choice in the matter and often don’t know when they are going to be tega-ed.

            We made it back to her house before dark (5:30) to cook dinner. It isn’t safe to walk around at night, and if you do, people assume you are up to no good. She had electricity, which was nice, but no running water (which made washing dishes a bit more challenging). Tandi told me more about the Peace Corps while we ate, and afterwards, we read for a bit and fell asleep around 8:30.

            The next day, she took me to the NCP (Neighborhood Care Point). There were several in the community, but this one in particular was also the kagogo, which is the central meeting place for the community. I met the secretary of the kagogo, and he asked me lots of questions about Baylor. No one in the community knew about the clinic, and he was curious as to who was eligible to go there, if it was free, and how they could become an outreach site. Most of the people wouldn’t be able to afford the 42 Rand (6
US $) it would take to go to and from the clinic, so ideally, he would get Baylor to come to the community.

            The NCPs are where orphans and vulnerable children can come for the day to receive meals and a bit of education. Tandi said that the community was pretty good about taking in the children but struggled to support them. Then NCPs filled this gap and provided as much support as possible, although often, it isn’t enough either. Talia (Canadian who visited with Rachel and Lindsay) worked a lot with orphans in
Botswana. One of the services her NGO provided was gift baskets for the orphans. Once families learned about this, they started taking in as many orphans as they could in order to receive the baskets, which they would then sell. The orphans remained just as abandoned and starving as before. Tandi said that this wasn’t really a problem in her community, but there were many others. For example, an orphan could go to school if they could prove (with death certificates) that they were indeed orphans. This is virtually impossible for many reasons. Many of them never knew their fathers, who left the mother when she was pregnant. Even if they knew both of their parents, no one gets a death certificate unless they go to a city far away and deal with some complicated legal procedure. So, unless there is someone who cares enough for the child to deal with the hassle and who is wealthy enough to afford it, there is no way for the orphan to prove their lack of parents. Thus, all they are left with are the NCPs.

            I listened for a bit as Tandi and the secretary discussed some of their projects—a community garden, fundraising for NCP renovations (most of them were dirty, stick-in-the-mud structures), education campaigns, and other events. During this conversation, I discovered that children become sexually active as early as twelve. I also learned that men fear the HIV stigma more than women (probably because it might limit the number of girlfriends they could have), while women were much more open and willing to address the problem. He told us that there was an article in the paper about a doctor who was telling many of his patients that they weren’t actually HIV positive even though they’d been told at a VCT (volunteer counseling and testing) clinic that they were. He thought they were lying about it because they were afraid that they would lose their jobs if the HIV rate dropped and funding for HIV/AIDS programs dropped. Tandi responded that it is much more likely that the one doctor was lying than everyone at the VCT’s, and in addition, many people try to place blame elsewhere in order to avoid taking responsibility for their actions (that caused them to get the disease).

            After that, I visited the school and nearby clinic. They were pretty much what I expected—about the same as the Vuvlane clinic, and the school was much like the school I worked at in
Nicaragua. We looked at the picture of the map Tandi was painting with her class and I took photos of some of the HIV/AIDS awareness signs. Realizing that her watch had stopped, we rush off to catch a combie and make our way back to Manzini. At that point, we split up. She heads over to her friend’s community to help with a workshop, and I head back to the COE in
Mbabane.

            When I get to the COE, I find that the rest of the Rice crew has arrived and we are to do the presentation and interviews that afternoon (originally scheduled for the next day). Other than the fact that I felt and looked pretty gross from being out on the homestead for two days, I think it went okay. Dave and I gave our presentations on WFP (from previous weeks), and then we discussed our challenges and experiences and answered questions about our projects and the internship. I felt a little awkward, since they had a camera following us around the whole time, but later that night we had dinner at Edlanlene (traditional Swazi food), which was much more informal and relaxed. We talked a bit more about our experiences here and what we thought future internships should involve or avoid. We also talked about what would be necessary to affect a behavior change here (ie: TV star verses the king) and I got to hear about what else the profs were working on back in Houston. We also met up with some of Dr. Ryan’s friends from home who were here looking at point-of-care diagnostics from a business perspective, so Dr. RRK and Yvette talked a lot with them about the overlap between their projects and possibility for collaboration. It was interesting to say the least, and the food was fantastic and authentic as always.

            The following day was a bit hectic. I discovered that the volunteers had been filling out the books incorrectly, so I had to spend some time fixing that and explaining the correct way. Also, that morning, I attended another WFP meeting, which was much more boring than the first. I think I made it through the first one because it was all new and exciting, but really the meetings are pretty irrelevant to the work at the COE. We go over the minutes from the last meeting, then talk about supply issues (ie: there have been tons of shortages, and many of the distribution NGO’s are only getting ½ of what they need. Luckily the COE hasn’t been affected yet. In Tandi’s community, they haven’t received food in 3 months!) and finally about challenges and problems (this is the part that takes forever and is irrelevant to the COE). One sight had problems with their delivery truck; another had problems with supply shortages. In fact, people have been threatening to attack the delivery trucks, if they don’t start delivering more food. Some people were actually arrested.

Anyway, there is really no need for them to have the meeting every 2 weeks. The individual problems could be dealt with through email much more effectively and efficiently, and the information about the pipeline (ie: getting food to the sites…supply, transportation, etc.) could be dispersed by email as well. Anyway, after that, I needed to finish filling out the WFP forms and go over them with Mlu and KT (work here permanently, so when I leave, they’re responsible for WFP). Overall, it was a hectic yet boring (especially after spending two days with Tandi) day, but it was nice to see the new volunteers working the WFP table. Now I’ll have the time to work on other smaller projects I’ve been attempting for awhile, so that’s exciting. Also, Carrie mentioned to Tina (another doctor) that I was interested in doing adherence stuff with outreach, and Tina said she actually had something already in mind. So, now I’m going to help out with the initial field test. I’m particularly excited about this because it means I get to go to more rural clinics and see more of Swaziland.

            That night, the Rice crew returned to the clinic after visiting various schools and clinics. They did their final interview of me and Dave and headed out. I think their next stop is Lesotho, then Botswana, and finally Malawi (locations of all the other Rice interns).

Tessa12: Weekend Fun

July 5th, 2007 by Tessa

Saturday morning, Rachel, Lindsay, Talia, Chris, and I all went hiking with Keith and the rest of the hiking club (people I normally hike with on Saturday mornings). While the hike was fantastic—better then the previous two hikes—it lasted quite a bit longer than normal, and none of us brought enough water or food. Everyone seemed to have a good time regardless, and generous man that he is, Keith brought us to his wife’s store and gave us all cold beverages. Diet coke has never tasted better. He also insisted on calling his son to see if he could drive us to House on Fire that night. (We had been talking to him earlier about our evening plans). I felt so bad dragging his son into it, but he and his friend didn’t seem to mind. So all six of us headed over to
HOF to see Malaikah, a popular South African band. Quite a few of the doctors from the clinic were there that night, as well as some other people I’d met at soccer (there’ve been soccer games on Wednesday nights) and a couple of Rice people who were in charge of setting up BeyondTraditionalBorders (my internship program).

The next day all six of us drove over to Mantenga (about a 30 minute drive), where we saw a beautiful waterfall and visited a cultural village. In the village, they showed us some of their ceremonial dances, which apparently are very representative of what actually goes on in Swazi villages. It involved a lot of stomping (on the men’s part) and high-kicking (on the women’s part). At the end, they grabbed all of us, and we did the choo-choo train dance and listened as they sang “In the Jungle” (from the Lion King). After the festivities, they took us on a tour of their village of thatched huts. I ended the day with a consultation with their Sangoma, which is a medicine man. From him, I learned that there is someone close to me trying to cast evil spirits on me. This person was close to a Swazi woman and an Indian woman as well. He also told me there was a man who was in love with me and trying to curse me so I’d fall in love with him as well. That part was pretty funny because about an hour later in the grocery shop, a Swazi man approached me, looked me straight in the eyes, and told me that he was in love with me and would buy me lots of chocolate. Everything else he said was pretty boring…I’d get married, have four kids, the first born would be a girl who liked computers, and a few random tidbits about my ancestors and sprinkling sea water on my clothes for good luck.

Tessa11: Healthcare Outside the Clinic

July 5th, 2007 by Tessa

dsc03137.JPGSorting through ARVs at Vuvulane Clinic

Photos Above: 

1. Vuvulane Clinic

2. A nurse from Good Shepherd Hospital and I are sorting through a container of ARVs

Wednesday, June 27 to Friday, June 29

               After two days of WFP work, I was able to escape the clinic and see a bit more of the healthcare facilities outside of the Baylor world. Wednesday, I went with Carrie and Julia to Vuvulane, a rural community about 2 hours from the COE. The clinic was run by nurses, and the only doctors ever out there were the Baylor doctors once a month. We met up with Good Shepherd (hospital in Manzini) nurses who have been going to these outreach sites before Baylor got involved. They provided the connections and the ARVs. We provided the medical expertise. I spent the day with one of the nurses. I was “helping” with pill-counting, but really I was just watching. The nurse was super nice and seemed to think I was just great, so we had quite a bit of fun while we worked.

              As I watched her work, I kept noticing things she was doing incorrectly (as she filled out the adherence sheet). The whole point of pill-counting is to see how well a patient is adhering to their drug regimen. It is very important because if a patient has poor adherence, then their virus will build resistance to the drug, and the patient’s viral load will increase. Basically, they will get sicker, and they will be much harder to treat in the future.) So, I started asking her questions about why and how she did what she did. Like, when she wrote down 56 for the expected number of pills, I asked why. She said that the patient needed 2 a day, and since there are 28 days between visits, they should’ve taken 56. Looking at the records, I could see that there were 30 days between this visit and the last. When I asked her about that, she said, “We always do 28. That’s just what we do.” And that was that. There were quite a few other major problems I observed with the system, but ultimately, it was all meaningless, since they never calculated their adherence percent. And even if the person clearly had terrible adherence (one man had 50 extra pills!), they never counseled them or took them off the ART (anti-retroviral treatment). Drug resistance has implications for not only the individual who isn’t taking his meds correctly, but also anyone he passes the disease onto will suffer from drug-resistant HIV.

            On the way to and from Vuvulane, we drove byHlane National Park, where Carrie was lucky enough to see a lion. I was rummaging through my bag and missed it completely! L On the way back, we stopped at the private Mbabane hospital, which was much nicer than the government hospital but still had much to improve upon before it would ever meet American standards. We were checking up on a premature infant that was born at 28 weeks (I could be off a few weeks there). I had never seen a preemie before and wasn’t quite prepared for it. The mother even asked me if I was afraid of the baby because I stayed by the door and stayed there throughout the visit. The baby was miniscule—the diaper engulfed its entire body, and its leg was the thickness of my thumb. What I was afraid of was giving the baby some germ from the outside world that would do its premature immune system in. Carrie told me that a neo-natal unit in the states would be 10x quieter and darker to simulate the conditions in the womb. This poor baby had a bright beam of sunlight pouring over him, in addition to a symphony of construction sounds reverberating from somewhere nearby in the hospital. Julia said that if the baby had been in the government hospital, there is no question that it would be dead by now.           

            On Thursday, I shadowed Dr. Eileen at the government hospital. Although I’ve never been interested in clinical medicine, and I never will be, I found rounds to be quite interesting. She and Dr. D (doctor at that hospital) went from bed to bed examining patients, asking the mothers questions, and looking at x-rays. One of the biggest challenges was deciding whether they had a weakened immune system due to AIDS or TB or both. Sometimes the x-ray clearly indicated TB, but with some patients, it was more difficult to tell.           

             One of the most exciting things about our visit was the fact that, when we arrived, Dr. D and some nurses had sat down all of the patient’s mothers (this was the pediatric ward) and were discussing the importance of washing hands and boiling water. This may seem insignificant, but in fact, if they can effectively communicate these messages to the mothers, they could more than halve the number of patients that needed to be there. They plan to do a lot more of this sort of doctor-patient interaction, and they were also trying to make signs to accompany the campaign. In that respect, I was able to help. Making those signs is one of the smaller projects I’ve been working on.

                On Friday, I presented an updated plan for WFP. Thursday, we had a volunteer come in, and Dave started training her. The plan for the following week was to transition from the old system (where Dave and I are very involved) to the new system (Dave and I won’t be here to do anything). A lot of the doctors weren’t there, so that kind of caused problems, but nothing too big.           

                Friday night, Lindsay and Rachel (two Rice students working in Botswana) arrived with Talia and Chris, two Canadians they had met in Botswana. They’d been traveling since 4 am, so we all just ate dinner and hit the sack.

Cough, cough.

June 30th, 2007 by Dave

Yeah, so I haven’t blogged for quite some time because I was hit by a very unsavory Swazi virus this past week. And there’s basically nothing I can do but get a lot of rest and hope that my tonsils will stop being so on fire soon. Apparently, it’s flu season in Swaziland, and when you work all day in a waiting room filled with little kiddies . . . well, there’s no escaping it.

In other news: Lindsay and Rachel (two other Rice kids in our program) have come from Botswana to visit us here in Swaziland! And, they’ve brought two Canadians with them! And my house is now full of people!

Also, Yvette and Lauren (two ladies that are in charge of my program) are arriving today.

And, on Tuesday (I think) Dr. Richards-Kortum and another professor from Rice are coming along with a camera man–to film us for a day! Ay! How frightening! I hope I’m feeling better for that!!

Later today, I’m heading off to the Swazi Cultural Village (possibly more on that later) and then to dinner at an especially savory restaurant called Edladleni that serves traditional Swazi food! Mmm-mmm!

Well, that’s all for now–Veronica Mars is calling (Thank you Devon!).

Tessa10: Patient cases and more WFP stuff

June 26th, 2007 by Tessa

Okay, so about last Friday’s meeting…

The woman being discussed was in her late teens or early twenties. I can’t remember her exact age. She and her baby both have HIV. It took forever to put the woman on ARVs because the clinic staff  (doctors, social worker, pharmacy, etc.) are hesitant to start someone who is in an unstable situation. This is because it is extremely important to take ARVs correctly. This can be very complicated because some pills have to be taken on a full stomach; others on an empty stomach; some can’t be taken with other meds; some should be taken with others…and so on. Some patients may have 3 or 4 or more pills to be taken under specific circumstances. Things are further complicated when the patient can’t read (or simply chooses not to read the directions). Anyway, this woman finally was started on ARVs because of her desperate need. The first few months, she had terrible adherence. Once, she said she had misunderstood the verbal directions and hadn’t read the written directions. Other times, she simply didn’t know why she had so many extra pills left over. Then the social worker gave a little background on the woman (I’ll call her Sara). Her parents were dead, and she has one brother who she doesn’t get along with. She lives with him and his wife, who also dislikes the Sara. When she was young, kids at school would call her an alcoholic and other names because her grandmother ran a liquor business. They beat her as well. When Sara reported this to her mother (then alive), her mom replied, “Well, just don’t go to school.” So her education was ended prematurely.

Currently, she has no work—no source of income, what-so-ever. The father of the baby lives in
Johannesburg and refuses to help. His one suggestion to her was to leave the baby “with his people” and they would keep and care for the baby. Clearly, the mom isn’t going to abandon the baby with people who could care less abut it. The question posed by the social worker on Friday was whether to start the baby on ARVs or not. If the baby didn’t receive them, his health would quickly deteriorate and he would die. But if they give the medicine to the mother, and she doesn’t dispense it properly, then the baby will build up resistance to the first line drugs, and for the rest of his life, he would be extremely difficult to treat (because the usual drugs would be ineffective). Another suggestion was that the mother actually wanted the baby to die (while this isn’t common, there have been situations like this encountered before). At that point, someone suggested they call
Swaziland’s equivalent of social services (I’m not sure what it was called exactly). But another person pointed out that they never have shown up all the previous times they had been called. In fact, recently there had been a suspected case of sexual abuse of one of the children at the clinic. COE staff called multiple times, yet no one ever checked into the situation.

At the end of the meeting, the general consensus was to give them the ARVs regardless of the social situation. Many people at the clinic felt that, whether or not the mother cared for the baby, it was the clinic’s duty not to abandon it. What is in the COE’s control is whether or not the baby has the opportunity to receive the drugs. At this point, the social worker mentioned that the mother had actually said she was not ready to give ARVs to her baby. The reason was unclear, although Sara’s doctor suspects it’s because Sara knows how complicated a baby’s ARV regimen can be (since it involves liquids, not pills). At that point, the discussion was ended with the vague conclusion that the social worker would have to talk more with the mother.

The second case discussed was equally interesting. A baby who lived in a very stable situation had been started on ARVs a while back. The family had an income, and the uncle of the baby was an HIV/AIDS activist who travels around the country educating people about the illness. Thus, the mother of the child was very aware of the danger of non-adherence. Anyway, the child’s doctor recently took him off of the ARVs because adherence was terrible. The mother could not explain why. She once said that she can be forgetful, but that she knows she didn’t forget… unless she forgot that she forgot. After telling the social worker this, she was given one more chance to improve adherence, and sadly, she failed. When they took the baby off the ARVs, she begged them for a 2nd chance, but they had already given her many, many chances. So the question in this case was what to do to improve the social situation so that the baby can begin ARVs again. Also, they had to figure out how much resistance had developed to certain drugs. If there is resistance, the drug regimen will have to be changed, and it is likely that when baby starts again, the regimen will be even more complicated.

I thought those two cases were particularly interesting. They give a realistic picture of how difficult it can be to run a successful ARV program in a developing country. Also, they bring up the issue of ethics again (I think I talked about that in one of my earlier blogs…) Choosing which is the lesser of two evils is always hard.

After the meeting, almost everyone in the clinic helped me pack bags of corn-soy blend. This is by far the least fun part of the WFP program, and the fact that so many people helped meant a lot. It was actually even fun because I got to know so many of the staff members better. Before that, I had met them only briefly. Thanks to their help, we managed to fill almost enough bags for the entire week.

And one last update on the WFP program…

Today I started contacting the list of approved volunteers. One woman is coming in on Thursday for the first official WFP training day, and hopefully I can reach the other woman for Monday. Shifting over to a new system is going to be a whole new challenge—We have to change a lot about how we register patients, assign numbers, and distribute food because the volunteer will not have the access we have to the electronic medical records. Luckily, we have the majority of the patients registered already, but I’m certainly glad we are starting early.