St. Lucia

Footprints on the beach, Cape Vidal

Our travels in southern Africa continue and we spent the last few days in St. Lucia, South Africa. We rented a car, picked up our friend Rebecca who is working Siteki, Swaziland and headed for the border. As we were filling out forms at the border Rebecca and Leah had their first opportunity to write "physician" as their profession! They are both officially done with all of their medical school rotations and now just have to graduate.

With two physicians on board we drove down to St. Lucia, a small, tourist town on the western coast of South Africa. As we drove in it reminded us a little of Florida -- quite different than any other towns we have seen while here in Africa. Very touristy, lots of surf shops and restaurants (and a lot of white people). Rebecca's roommates from Siteki, Nick and Dan, had arrived in St. Lucia a few days before and were staying at the same hostel. It was fun to travel together with them again.

St. Lucia estuary is a large coastal park that has several different ecosystems within the park. It was amazing to drive around the park through savannas dotted with the acacia tree, pass an estuary, and then end up at the beach on the Indian Ocean with large dunes. We saw several large antelope species with beautiful antlers, a few monkeys and a baboon. The park has rhinos and elephants, but they must of been hiding while we were there. We spent most of the day at the beach body surfing in the waves, playing frisbee and reading. Doesn't everyone celebrate the end of medical school at a beautiful beach on the Indian Ocean? That night Mike bought a huge, fresh red snapper and grilled it for us for dinner, it was delicious!

One reason we picked St. Lucia as a vacation destination was for the snorkeling, which we heard is supposed to be really good. Unfortunately this didn't work out, but it wasn't for lack of effort on our part! We tried so hard to go snorkeling, even getting up in the rain at 5:45 to get out there for low tide. We got out there with our snorkeling gear walking past the people there to fish who looked at us like we were crazy and once we saw the ocean we realized why -- it was so rough and choppy. Too bad, next time we are in South Africa we will definitely have to go snorkeling!

Our next adventure is Phophonyane falls here in Swaziland for a night and then up to Kruger National Park in South Africa for several days. We can't wait!

Island Paradise

We finally took a real honeymoon and spent the last several days on Ilha de Inhaca, an island off the coast of Mozambique in the Indian Ocean. Inhaca is 40km from Maputo, a large coastal city in the southern part of Mozambique. It was everything I imagined an indulgent, beach honeymoon to be, except for the transportation...

If you ever felt cramped flying to a tropical paradise in the middle seat on a plane you should try riding in a kombi for three hours. Mike and I were stuck in the back corner with two rather large ladies, it was packed tight. We arrived in Maputo for a night and were followed down the street by people wanting to sell us anything and everything. I couldn't wait to get out of the city and off to my tropical paradise that was awaiting me on Inhaca. Early Saturday morning we made it to the pier to board a old, but functioning ferry. The ferry had a mix of tourists and locals, this was going to be great we thought! Soon the island came into sight and eventually we were close enough to see that there was no pier or dock for this large ferry, this was about the time they threw the anchor overboard. A few very small dingy's with outboard motors pull up to the side of the ferry and eventually people were lowering themselves down the side into these small boats. We now realized why the hotel recommended flying and why no one else on the ferry had luggage like us. We lowered down into the ferry (I could barely reach!) along with too many other people and the boat was sitting only a few inches above the water. Thank goodness it was a calm day or we would have been swamped. They seem to have a habit here in Africa of trying to cram too many people onto one small form of transportation, again this was true with these boats. Our boat was filled to the max and we took off for the island, of course our fee for the ferry did not involve this short trip and we were asked for money again if we wanted to make it to shore.

Our island paradise was pretty much everything I wanted. When I first met Mike he said we would never go on a vacation that didn't involve snow, so this was a long time coming! We sat by the pool overlooking the ocean drinking our new favorite drink -- caipirinha, a local drink with lots of lime, sugar and rum. We only got up from the chairs to eat and occasionally to play tennis. It was perfectly relaxing. There was seafood in abundance and we ate to our hearts content -- we have fill up on it before we move to Utah. The dinner our last night there was the most incredible. I signed up for the honeymoon special (it was actually cheaper) and we were treated to a private dinner on the beach with candles, flowers and bug spray to keep away the malaria carrying mosquitoes. The served us plates piled high with grilled prawns, lagosta (very large cray fish) and barracuda, it was incredible.

As much as we enjoyed our indulgent vacation we felt conflicted by the fact that just outside the resort and on the beach we watched all day local people were so poor and just trying to make a living. I think this is hidden from many of the resorts that American travel to, but it was right in front of us in Inhaca. I guess the least we can do is come to their island and support local tourism, but it was tough to think that what we spent on one night at the hotel was all they probably made in a few months. At least children living on an inland will likely never go hungry -- teach a man to fish and you feed him for a lifetime.

We decided to take the small plane off the island because we were a little worried about getting back on the ferry with all of Mike's camera gear. Unlike the kombi, ferry and small boats we took the ferry was not overcrowded.

Now we are back in Mbabane, only to take off on more travels. We will tell stories when we return!

Leah and Mike

Two more days on the homestead with Young Heroes

A double orphan in the Young Heroes program....

...and her support system; her gogo (grandmother)...

...and her cousins

I did two more days of photography for Young Heroes this week. It's been a fascinating way to see much more of the real Swaziland than I otherwise would have seen. Swaziland is a tiny country - yesterday we literally drove across the country and back again. Homestead living conditions are often very harsh and primitive, but at the same time the settings can be incredibly beautiful.

A few stories from the homesteads:

Four children, the oldest 14, were orphaned when both of their parents died, most likely from AIDS. The grandparents, who live nearby, at first thought it best to take the children onto their own homestead, so they burned down all the huts at the orphan's homestead. Later they reconsidered, thinking that it would be good for the children to have their own homestead after the grandparents pass away. A house was built on the old homestead for the children to live in. The orphans now run their own homestead and spend most of their days with their grandparents. When we visited, one of the girls was helping her grandparents out by grinding the harvested maize into meal. The gogo was cracking open Marula nuts from their tree, from which she was collecting seeds in a bucket. Phephe later explained that when she fills up a 5-kilo bucket with these, she can sell them to an oil producing factory for 50 Emalangeni (about $7 US). After half a day of cracking nuts, she had about a quart of seeds in her bucket. The oil factory is owned by the Queen Mother.

Some of the kids we visited seemed relatively healthy and happy in spite of their circumstances. This was not the case for one homestead that we visited yesterday. The orphan, a teenage girl, would barely speak or look at us. She has AIDS and has been taking ARVs, but just recently started refusing to take them. She seemed to have given up on her life. Witnessing her emotional pain was the toughest thing we saw. The three of us - Phephe, Guligani (the Young Heroes program director) and I - were very quiet back in the car.

I tried to photograph the people and homesteads in a very straightforward way. I wanted to include both the harshness of the living conditions on the homestead and the sublime beauty of the environment. In taking portraits I wanted to give the homestead residents the best opportunity to present what they want to show to the camera. Being photographed is not an everyday occurrence for them, so candid portraits are not possible. In general both the children and the adults very much appreciate being photographed.

On the way back to Mbabane yesterday Phephe stopped on the road adjacent to the sugar plantations to buy a massive sugar cane for 2 Emalangeni (25 cents). Each of us broke off a section to suck juice from. We had Brendan's (an American working for Young Heroes) Bob Dylan CD on the stereo. Guligani, who directs a choir in his spare time, was not impressed with Dylan's vocal work. I was again reminded of how small Swaziland is when we passed Phephe's parents on the road through Manzini.

Young Heroes website

Mike

Mbabane Government Hospital

I spent the day on Ward 8, the Pediatric Unit, of the Mbabane Government Hospital today. What an amazing experience, eye opening and very sad. I saw a very different style of medicine than the medicine that is practiced within the walls of the Baylor COE clinic. This hospital has limited access to resources, food for the patients and basic medical supplies that should be abundant at a hospital.

The pediatric ward is four large rooms with numerous cribs/beds in each room, approximately 80 beds. Two cribs will be right next to each other and the parents are seated by their child's bed. The parents must stay with the children at all times as there are only about 2-3 nurses for all the pediatric patients. The parents are responsible for giving all of the oral medications and food to the kids. This hospital does not provide the antiretroviral medications that patients with AIDS need and the parents must leave the hospital to bring their children to our clinic to receive refills on medications. Leaving the hospital means they could miss any IV medications they are supposed to receive or miss the calorie rich formula they bring up to the ward a few times a day for the malnourished patients (all of them).

I noticed a few things on arrival to this hospital that quickly made me realize I am working in a developing country. One of the rooms on Ward 8 is the pediatric intensive care unit, it is called the intensive care unit because they have oxygen available in that room. No ventilators, no medical equipment to care for critically ill children, only oxygen. Next I saw a young child about 1 year old in a crib that had several bars missing on the side, if this child moved around he could easily have fit through the hole (I could have fit through the hole, it was large). As we rounded on the children there was a child with advanced stage AIDS who was extremely malnourished in the crib next to a boy with a pneumonia who was coughing right towards her. There is no such things as infection control at a hospital in the developing world. I saw bed sores that were not being cared for properly with appropriate dressings. Another patient last had her blood drawn on April 2nd at which point her hemoglobin was extremely low at 4.8. She has not had another blood draw since that point, and she has been vomiting blood for the past couple of days.

The patients here were extremely sick and many are admitted for malnutrition which requires a rigorours re-feeding program. The hospital is supposed to proved the appropriate formulas for the patients, but unfortunately this is not the case (they were out of milk when I was there). These children are losing more weight while they are in the hospital! And it can take well over a month for them to finally gain enough to go home. This is the hospital in town, a place where children are supposed to heal and thrive. There has to be a better way to care for these kids, a safer, more sanitary way where the kids could at least have enough formula and access to medications. It is one of the many challenges of practicing medicine in the developing world that I had only heard about in medical school, now I am experiencing it first hand.

Leah

Baylor International Pediatric AIDS Initiative

Baylor College of Medicine - Bristol-Myers Squibb Children’s

Clinical Centre of Excellence, Mbabane, Swaziland

This is the clinic where I am spending the month -- it is called the COE short. It is a spacious, newly-constructed building where children and their care givers can receive HIV testing and treatment. It walls are adorned with Swazi handicrafts, cultural garb, and various local photos. A safe, clean place for the children of Swaziland and their families to receive medical care -- this is a rarity in Swaziland. I knew that many of the buildings built by the Baylor International Pediatric AIDS Initiative were modern, but I never expected to find new oto-opthamoscopes (to look in eyes and ears), a light box (to view x-rays) and computer with electronic medical record in every room. This is more than most of the offices I have worked at in Vermont had available. Working in such a modern setting is a complete dichotomy from the patients who I see daily. Occassionally I have to remind myself that I am in an area of the world that has very limited access to medical care. Unfortunately these reminders come too often throughout the day. I see numerous HIV infected children who are severely malnourished, suffering from infections caused by drinking bacteria infected waters and struggling to stay alive. I have seen many children with Tuberculosis and even a few with advanced kaposi sarcoma, a tumor associated with AIDS. I have never seen patients like these in my four years of medical training in Vermont. In fact I had never seen a child with HIV prior to coming to Swaziland.

The funding to build the clinic came from Briston Meyer Squibb and it is staffed by physicians from the Pediatric AIDS Corp who are hired and trained through Baylor. Most of these physicians are American pediatricians who recently completed residency. The physicians are here to train and assist the Swazi medical staff to treat children with HIV. Unfortunately there are few doctors and even fewer pediatricians in Swaziland. The only medical training in the country is a nursing school. Many nurses are quite knowledgeable about HIV, but cannot distribute the anti-retroviral medications. Swaziland needs more doctors, and this is where the Pediatric AIDS Corp physicians come in.

Every morning starting around 7 or 7:30 women and their children start to fill the waiting room. Women often travel quite a distance on the Kombi's with their children to be seen at the clinic, and they come every month for refills on their medications. This is quite an expense to these poor women of Swaziland, but once inside the clinic all of their medication is provided for them by funding from the government. Dehydration is so common here that the waiting room has a large cooler of ORS -- oral rehydration solution -- that the parents can start to give their children before they are seen by a physician. The clinic has a model program for HIV care; as I travel to other clinics in the country I see that it is not this way everywhere. Once a patient is in the clinic the children and their care givers work with nurses and social workers to learn about HIV, nutrition, dispensing medications, etc. Then the patients meet with the doctor, and often these visits will last for quite a while as there are many concerns and issues to discuss.

When a patients CD4 count (the cells attacked by HIV) is low enough we start the anti-HIV medications called antiretrovirals. We also have an excellent adherance training sessions that must be completed prior to starting anti-retroviral drugs. Adherance to the medications is very important to prevent resistant strains of HIV. And once you start antiretrovirals you are on them for the rest of your life. These families have had little exposure to the medical community and certainly don't have the same familiarity with prescriptions as we do in America. Imagine what it must be like to suddenly have to start on three anti-retrovirals twice a day, and a prophylactic antibiotic and a multivitamin daily. Many of the antiretrovirals must be taken every 12 hours and many of our patients don't have 't have electricity at their homestead, no clocks, no TV, no radios to remind them. Then the added challenge of having to give these medications to a small child! I am sure it is quite a culture shock for many of these patients! The adherence counseling helps to alleviate some of the unknown for the patients and keep them on their medications.

The model of HIV care offered at the clinics is pretty unique in a developing country, but I hope it is a model that we can strive for throughout the world. Everyone deserves this type of medical care in a safe and up to date facility. Despite the high standard of care given within the clinic there are times that medical treatment is quite different in than in the US and I am again reminded that I am in a developing country. There are few resouces available beyond the walls of the clinic and patients who would go to the hospital for IV antibiotics in the US are often sent home with an antibiotic and instructed to return in 2-3 weeks. These physicians here are up against a lot and are giving the best possible care that they can given the circumstances. I am honored to be part of that for this month.

Leah

Our first Safari!

Baby Elephant at Hlane Royal National Park

This post will be a little different that our last two, more uplifting and back to our travels around Swaziland. We rented a car this weekend with our roommates here (a resident from UCSF also working for a month at the clinic, his wife and 2 year old daughter -- so cute!). We rented the smallest car they had and the guy who rented it to us made a point of showing us the spare tire, ummm, was there a good chance we would need that?? Mike tried his hand at driving on the left side of the road and the hardest part was the blinker. He kept signalling his turns with the windshield wipers, whoops! I was the worst back seat driver, so concerned that he was driving too close to the side of the road where there is no shoulder and at some point a large ditch. We thought we wouldn't be so nervous on the roads in Swaziland if we were in our own car instead of travelling in a Kombi. But driving with the Kombi's on the road is just as terrifying as being in one. They are crazy drivers! We survived and by the end of today Mike was actually using the blinker, not the winshield wipers.

Yesterday we went for a hike in Malolotja, a nature park about 30 minutes from Mbabane, in the mountainous northwest part of Swaziland. It was beautiful there, but really hot! We had a sweltering hot hike in the plains with very few trees. We could see a river and waterfalls, but our trail did not actually go down that way. Oh well, we lasted a couple hours and then went for a drive in the area. Swaziland is a really beautiful country with several different types of landscapes within such a small country.
Today we took off on an adventure with Dan, Meredith and Sophia that started at the Cuddle Puddle in the Ezulwini Valley. This is a hot springs area that apparently lives up to it's name in the free, down stream section. We went to the up stream section that you had to pay for. After stopping at a craft shop that supports Swazi women we headed off to Mkaya Game Reserve for a driving safari. We arrived at the gate of the game reserve to find that we had made reservations somewhere else and this park is not open to public vehicles. Crisis averted when we called up Hlane Royal National Game Reserve about an hour away and they were able to accommodate us all on the sunset safari tour.
We arrived at Hlane to see the hippos in the pond and have lunch before our 2.5 hour open Land Rover tour. Our ranger/tour guide was named SonnyBoy and we were joined by another family who are missionaries from California doing HIV work in South Africa. As the ride started the mother prayed to Jesus that we would see some animals on the trip -- apparently it works! We saw several elephants, including a few baby elephants, who came within a few feet of our car. They are huge animals, I cannot believe we were so close to them. Then we saw several lions, including a few cubs and a male lion, lounging on the side of the dirt road we were on. It was amazing to be so close to the animals and we felt safe up high in the Land Rover and with a knowledgeable ranger. The animals didn't seem to care that we were there, the lions laid there while we stopped and had a beer that the tour guide brought for us! The whole trip was just incredible, we were so excited to see the animals.
So even though our original plans to go to Mkaya game reserve didn't work out I think that Jesus came through for us on the trip to Hlane! And we even made it home without having to use the spare tire.

HIV/AIDS epidemic in Swaziland

Angela from Young Heroes testing a child for HIV

I know I promised an entry about the clinic I am working at while we are here in Swaziland, I will get to that soon, I promise, again. One reason I have not wrriten is because Mike is hoarding the computer to do photography work, and I feel like people really just want to see his photos. So this is a prelude to an entry yet to come about my experiences at the clinic here in Mbabane. I want to set the stage and let you know the uphill battle that the doctors here in Swaziland face against the HIV/AIDS epidemic that is plaguing and killing this country.

As a disclaimer before I start -- much of my information about cultural practices here in Swaziland I learned about from the American doctors I work with here. Please don't take this as gospel truth, it could be a biased view that I am hearing while here. The facts about HIV rates are true even though they are absolutely unbelievable.

Swaziland is a country of 1 million people and located at the western edge of South Africa next to Mozambique. It is a small country, approximately 6,600 square miles, making it one of the smallest countries in Africa -- approxmately the size of New Jersey. The government is one of the 3 remaining monarchs in Africa, run by King Mswati III. This is a peaceful country with little to no political turmoil. It has been run by the same monarchy since the 1960's when they won their independance from the British. The king has numerous palaces through out the country. Desite his riches 69% of the Swazi population lives below the poverty line, defined as approximately US $22/month. The Swazi people appear happy with the king, but oppositional parties are officially banned. Even the paper seems to be run by the government -- there was an article today about arrests at a protest at a border crossing but we could not figure out what the protest was about. The skeptisicm to the government seems to come from foreigners, and this may have something to do with the alarming rate of new HIV infections and AIDS related deaths.

Swaziland has now surpassed Botswana as the country with the world's highest HIV infection rate. Yes, this small country has the highest rate of HIV infections in the entire world:

Infection rates in 15-19 year olds: 29.3%
Infection rates in 25-29 year olds: 56%
Infection rates among pregnant women: 42.6%

Take a minute to think about that, think about Mike's photographs, about every other person that he photographs is infected with HIV and will likely die in the prime of their life.

Why is this happening in this small country that few people had heard of when I first mentioned that I was going to work here for a month? HIV was likely first brought into this country by Swazi men who went to work in the South African mines. They would have sex with the sex workers around the mines, become infected with HIV and then return to their wives in Swaziland. The spread of HIV was further perpetuated by the fact that Swaziland is a polygamous society; the king currently has 13 wives. And it appears that dating many women, under the pretense that they are looking to take a new wife, is part of the Swazi culture. What appears to have the most impact in the impressive rates of HIV in this small country is the lack of public awareness and eduction campaigns. While some other countries, such as Uganda, have launched country wide educational campaigns to encourage condom use and single partners, Swaziland has yet to do so because it is not part of "Swazi culture". There is little understanding of the disease here and even less acceptance. A woman with HIV who discolses to her family can be kicked out of her husband's home and can lose her children as well.

It is a very sad situation, and even though I know the facts I cannot fathom the magnitude of the problem. Swaziland is dying, they are losing their adult population at an alarming rate. These are people who are supposed to be in the prime of their lives and support the economy, and instead they are stricken with a deadly illness. It is an unbelievable problem without a clear and easy solution.

I know that the Baylor clinic where I am working is part of a solution and they are do amazing things for both the pediatric and adult poplulation of this country. I cannot wait to share more with you about the work these wonderful doctors do here for the Swazi children and their care givers.

Leah