"This is the most reckless thing I've ever done. My dad would be so disappointed." -Chris Kohls, entering the St. Lucia Estuary

Our original plan was to spend our weeks in the hospital or at rural clinics, but due to a scheduling conflict with two upcoming TLC clinics, we shifted our plans and pushed our two longest treks (Kruger NP and St. Lucia Estuary on the Indian Ocean, both across the border in South Africa) against each other. As a result, we've just completed an 7 day trek across the northeastern part of South Africa. While we all were itching to get back to Manzini by the end and dive back into the medical aspect of our trip (our primary purpose here), the trip was one I won't ever forget. From dramatic animal encounters at Kruger to the chaos of South African highways (where 2 lanes actually means 4), my first speeding ticket (and a speeding, stampeding hippopotamus) to a brush (fire) with death, and braving "the most dangerous body of water in the world" in kayaks, these 7 days have been packed with plenty of (mis)adventure. I've taken over 700 pictures/videos over these 7 days, but given the slow upload speed over here, I'll have to share those once I return.

Our first trip was a 4 day, 3 night trip to the world renowned Kruger National Park. Roughly the size of New Jersey, it is impossible to cover the entire park in that time period (though I certainly want to some day). We stuck to the southern reaches of the park, camping at Skukuza and Pretoriuskop rest camps. We left Manzini early Thursday morning, barely got lost, and crossed the border with no issue. By about 1:30, we'd hit Kruger, and started plugging north for our camp. Due to the time constraints (must be in camp by 530 PM), we had to fly a little faster than we'd like, but in the 3 hour drive between the gate and Skukuza we stumbled upon two lions about 10 yards off the road, a White Rhino bigger than any we saw at Hlane, and several herds of elephants. The highlight was a Leopard in the middle of the road as we came around a bend near Skukuza (pic to the left). We managed a few looks, then tried creeping closer for a better look, when another car speeding around the bend spooked the cat. Without a doubt, the most beautiful animal I've ever seen.

The next morning, feeling inspired by our hot start the day before and fueled by Eland biltong (jerky) we pushed out into the park. We were rewarded with many different types of antelope, numerous elephants, and dozens of bird species. We pushed north, hoping for our new targets, Cheetah, Wild Dog, and Lion. While we had no success with these, we did have a number of good elephant encounters and took in spectacular views of the different valleys from mountain ridge roads.

Speeding back to camp for our night drive, we noticed a plume of smoke in the distance ahead of us; as we approached it grew thicker and darker. Nearing it, I noticed large numbers of Lilac-breasted Rollers flocking, and as we became nearer, Impala rushing out of the brush and embers floating around the car. As we rounded a bend, we saw a brushfire burning on the side of the road (not uncommon in this part of Africa, which has been experiencing drought for years); I shifted to the far right side of the road, and made a move to quickly slip past the fire. As soon as the car started moving, the flames licked out onto the road and the car became very hot, with gusts of hot wind from the fire reaching into the car. We all panicked, and quickly threw the car in reverse, squealing away as the fire continued to grow (luckily not striking any of the fleeing antelope as we did). We managed to find a dirt path around the center of the blaze, and made it back to camp just in time for our night drive, but a return to the area two days later showed that given the extent of the blaze (picture to the right... this extended about a km in the direction we had been traveling), we likely would have been in serious trouble had we not backed out of heat.

Adrenaline still pumping from the brushfire, we loaded up for a sunset drive. This guided trip is the only way to explore the park after dark. Our lamps didn't turn up much for the first two hours of the drive, continuing a feeling of disappointment after our predator "dry spell" that day. As we worked back towards camp, we ran into a number of hippos grazing out of the river at very close range, and stole a quick look at a Civet as it snuck back into the cover of the grass. The highlight of the trip came when the guide spotted a pair of lions on the road; for over 15 minutes we tracked them as they moved up the side of the path, marking their territory and resting. At that point, it was too dark for my camera, but I do have a bit of video I will share when I return! The 2 lions were definitely one of the high points of the trip.

The next morning, we broke out at dawn. For the first several hours, things were pretty quiet, though we nearly blew past two different elephants 3 feet from the road, and had great looks at hippos, crocs, and tons of waterbirds at close range at the Lake Panic Hide. On our way back to camp, we ran into one fo the famous Kruger traffic jams, and managed to maneuver into position to see 2 cheetahs no more than 15 feet away, tearing away at an Impala kill! Definitely one of the most thrilling experiences I've ever had in the field.

The rest of the day we worked towards our new camp, Pretoriuskop. Game was still thin at times (wild dogs still managing to stay out of our sight). We did see one massive herd of elephants, including the biggest elephant we saw on the trip, which, for a moment flared its ears and appeared as though it might charge our car. Later, a lioness paced out of the scrub. This cat was particularly impressive, powerful, and didn't seem to care at all about our presence. We tried to work ahead of its trail into the forest, to position for another road/river crossing, and failed, but it was almost as exciting to see all the antelope we ran into along the way picking up on its presence and spooking (including a herd of Kudu that exploded across the road just ahead of us... unfortunately no lion in pursuit).

That night, we were treated to a spectacular sunset from the top of the mountain near our new camp. We woke up early the next morning, again, hoping to strike gold with wild dog or lion. We managed to find one lion, at a distance, with apparently 3 more just out of sight beneath feasting on Impala, and a stop at Lake Panic again produced displaying hippos at close range. Trying to make it back before dark, we departed for Manzini.

Next morning, we picked up Kim and made our break for the second half of our adventure, this time south east into the KwaZulu-Natal coastal region of South Africa. About two hours in, I was pulled over and received my first speeding ticket (on any continent). In Swaziland, the police camp out at bus stations with radar guns, and walk into the middle of the highway to flag you to the side of the highway, and issue a fine on the spot. Papa Kohl's spotted the 100E fine (~15 US, and apparently a spike on what is normally charged, but a small price to pay for the street cred I've now got for being an international criminal).

St. Lucia is a beach town not unlike what you'd expect to find in Florida, at least at first glance, with lots of little places to eat and souvenir shops. We split north for Cape Vidal, our camp for the night, not realizing it sat in the middle of iSmangaliso Wetlands Park... what we figured was more South African highway turned out to be a winding trail through rolling coastal wetlands, dune forests, and savannah, complete with Rhino, Zebra, Kudu, and Buffalo. Eventually we reached camp, which sat directly on the Indian Ocean. We spent the remaining hour of sunlight exploring the beach and testing the water (not bad considering it is winter down here).

Next morning we woke up early and snuck to the beach to catch the sunrise, and were rewarded with dolphins and a few humpback whales breaching within binocular view off the beach. We broke camp and worked back to St. Lucia. Unlike Kruger, where most of the territory we explored was grassland or thorn scrub, the iSmangaliso park is made up largely by coastal forest, giving a much stronger "jungle" feel. We picked up a few new animals, and ran across another leopard. While it stayed at a good distance (no good photos), it stayed put long enough to get pretty good looks, continually watching us from an opening in the grass. Eventually, it moved on, slowly pacing out of sight into the brush. Favorite animal of the trip, by far. I'd highly recommend a visit to this park; while it lacks the fame of Kruger, I think it boasts better scenery, has the highest density of leopard in South Africa, allows more opportunities to get out and walk (the concrete paths to the hides were left open overnight to dry, and each has several tracks of footprints permenantly embedded into it, including leopard and hippo tracks), and is much less crowded... definitely worth a stop.

After spending a couple hours on the beach, we took a "Kayak Safari" with Justin, a local fisherman/guide. We entered the water and paddled up to a bank with a couple of huge Nile Crocodiles... the beast behind Brad and I was over 4 m long (over 13 ft). We continued paddling, eventually coming across a group of hippos submerged in the estuary. We sat and watched while they displayed, gaping their jaws, even rising out of the water once trying to intimidate us ("Yes, that is for us, to show how big they are", according to Justin). Most frightening moment (keep in mind that hippos kill more people than any other animal in Africa) was the paddle back. As the sun was fading, our guide stopped us as he had spotted a hippo in the middle of our path ahead. Hippos can submerge for up to 7 minutes (though usually 2-3, which still seemed like an hour) before coming up for air, staring you down each time, so each time they dive, your heart hits your throat waiting for it to rise back up beneath your boat. This was the first time the guide actually seemed concerned, as each time the hippo appeared closer and closer. After about 10 minutes we finally spotted the hippo behind us, and headed back in. Overall, an awesome experience (the videos are even better than the pictures), and as a bonus, the estuary was busting with bird life. That night, thinking our hippo run ins were behind us, we headed into St. Lucia for dinner. Walking down the street and stepping off the curb, we heard someone whistle loudly. We stopped and had no time to react as an adult hippo barreled past us at full speed about 15 feet away on the other side of the road. Definitely should have looked both ways... apparently they frequent the streets of St. Lucia at night to graze and drink fresh water out of swimming pools.

The next morning, we took a tour through the gamepark and snorkeling in the ocean with Phillip, the owner of the kayak safari company, who filled us in a bit more on the paddle we'd just taken. While we knew the St. Lucia Estuary contained hippo and crocodile, apparently it also hosts a healthy population of Bull and Blacktip Shark and is largely considered (direct quote) "the most dangerous body of water on the planet". Even better, apparently several years before his death, Steve "Crocodile Hunter" Irwin camped for two weeks at St. Lucia but refused to do any taping in the actually estuary because of the danger (one of the only places he refused to film). With years in the area and having done work on past and future animal documentaries, Phillip was a fantastic guide, but I am glad he had to miss the kayak safari, because he was busy catching and radio tagging Black Mambas and Cobras (yeah, the guy is a complete B.A.) for a research study.

Early that afternoon, we burned back to Manzini. While we had no further incidents, driving through South Africa was another adventure. What appears to be a standard 2 lane highway (except with a ~70 mph speed limit) is treated as a 4 lane highway. Cars passing sugarcane trucks routinely blew by us with their cars straddling both sides of the white line. Drive was a little tougher since Brad's girlfriend completely let us down with her promise to supply mix CDs, a sin for which we probably can never forgive her. Thankfully we had South African radio stations to entertain us, which play interesting combinations of Enrique Iglesias, MJ, Jay-Z and Rod Stewart. All in all, a great week, though I was definitely feeling a little homesick for Swaziland and was pretty ready to get back to Manzini, RFM Hospital, and the TLC clinics.

Catch up...

It's been a pretty busy week and a half stretch over here, and I haven't really had a chance to catch up the blog. We geared up with TLC for two more clinics in the three days after Hlane, and on the third I followed Dr. Costa for rounds at RFM Hospital. Dr. Costa has been a fantastic teacher, pushing us with questions, and always keeping us involved with his thought processes and patient diagnosis, outlining both disease conditions as well as the methods used in Swaziland to treat these problems (many methods much different than American norms).

The two clinics we participated in were much larger than the first "warmup" clinic; in the picture to the left, only a fraction of the crowd Dr. VanderWal and Sipho are speaking to can be seen. The clinics start with talks about HIV and directions regarding the day's clinic from Pumi and Sipho, two of the veteran Swazi team members/translators, and Dr. VanderWal, as the rest of the team sets up the series of stations the patients will pass through. It is really a spectacle to witness as multiple trailers are unloaded, including all of the supplies for registration, triage/screening, and counseling, as well as the pharmacy; I have been particularly impressed by the way that Harry and Echo's team performs on the clinic days ("gameday"); on a given day hundreds of patients will be seen, and according to Echo, the TLC clinics screen more patients daily than any other operation in the country.

The first of these two clinics involved a large number of children; four different schools were brought together. Every child is screened for a number of problems, especially ringworm, scabies, and/or bilharzia (bladder worms aka schistosomiasis, the same worms that cause swimmer's itch, present in Elk Lake!), for which they then receive medication. We had the opportunity to learn on the fly and help Dr. VanderWal with the screening process; between about 8 of us, we picked through the scalps and scanned the skin of a few hundred children in about half an hour. After being screened, we helped distribute wrapped baskets to the children, donations from an organization called "Operation Christmas Child". Each is a shoebox, filled with gifts for the children, generally including toys, clothing, and toiletries; in addition, each gift is handed out individually, allowing for a lot of interaction with the Swazi children. We've learned that in this culture, children generally are not valued, and often used by adults as means to ends; the gift-giving gave us a chance to make the Swazi children feel cared for, and furthermore serves as a means for TLC to strengthen relationships with the communities they visit. After the gifts were distributed, we filtered into the crowd to show the (many) confused children how to unwrap their presents and try out their new gifts. It was definitely one of the most enjoyable experiences I've had thus far in Swaziland.

The first part of the clinic is devoted to screening children; as the morning, afternoon, and nights carry on, the team's focus shifts to the adults. We spend most of our time in triage, screening blood pressures, blood sugars, and HIV status. Our patient population is variable, as we test any ages, from infants to the elderly ("gogo"- grandmother & "mkhulu"- grandfather) in any willing patient of unknown status. Tests (to the right) require a drop of blood placed onto the test strip, which then filters up the strip and gives a result in a matter of minutes (two lines indicated a positive result, while one line a negative- the 3rd from the left and 2nd from the right above are positive). It is hard to gauge exactly how many Swazis test positive, but our group seems to agree that anywhere from 20-35% of our tests come back positive. Every test is encoded, with a test number corresponding to the patient's name and a + or - result indicated by otherwise unrelated letters to protect patient privacy. Working in triage allows us to contact a large portion of the clinic population; furthermore, it allows us freedom and time to interact; the typical triage can be performed in a minute or two, depending on the patient, and so often we are able to stay well ahead of the flow from registration. The last clinic, we all split time between work and playing with the local children, including the group of 4 to the left, who would pose for pictures, then immediately scurry over to see what they looked like on camera; every time, they would burst forth with squeals of laughter before quickly striking another pose.
Each clinic has carried into the night; in rural Swaziland, this provides additional challenges. Many of the school's we've visited lack electricity, so TLC carts in several generators to run their equipment. Much of this power goes to lighting, as the rural Swazi locations become pitch black by about 6 PM; in the picture to the right you can see a floodlamp behind Graham and Chris as they triage a "gogo". At times, the generators have been unreliable, providing additional challenges; I've even had the chance to draw blood using a headlamp flashlight.

The clinics have been without a doubt three of my favorite days so far on this trip. The well-oiled TLC machine is truly impressive to see in action and an honor to be a part of, even if small and temporary. While the striking number of positive HIV results is frustrating, especially when I can start matching test numbers to faces in my head, it is encouraging to know how many Swazi's are being made aware of their status, and being provided with the guidance and direction needed to start their treatments. As a medical student, I've had the opportunity to see some amazing pathology, many HIV related, and many of it not (most recently, caput medusae- distention of abdominal veins from liver failure that feels like a ball of snakes). Finally, the days provide plenty of chances to interact with the Swazis. Even while on the 7 day South African adventure we just ended, I've been looking forward to our next clinic on Friday.

Hlane

We took off this past weekend for our first solo trek, to Hlane Royal National Park, about 1.5 hrs from Manzini. The drive to the park itself was an adventure. Poor drivers, rough roads, flocks of livestock, and road edges that serve as sidewalks for large crowds of school children made our first swing at driving on the left side of the road (and shifting with the left) an even greater challenge. Within 30 minutes of leaving Manzini, finally feeling slightly comfortable behind the wheel, a pothole reached out onto the road, swallowing my left front tire. For a few tense moments, Graham and I tried to figure out if we'd blown the tire. Within a few seconds, the car responded, beginning to shake violently, and we pulled over. The tire was blown, hubcap thrown onto the side of the highway, and the rim bent in from the blow. I paced the highway, found the hubcap, and we went to work on the switch. For those not familiar with roads out here, there is not really any sort of right-of-way for downed cars or even pedestrians; little clearance was given by the cars and trucks that barreled past at 100-120 km/hr. After about ten tense minutes and a brief search-and-rescue mission for the hubcap, the spare was attached. Not a great start to our driving experience, but still excited to explore Hlane, we pulled back onto the road, and continued.

That hiccup behind us, we continued busting east towards Hlane, finally reaching the gate. We popped in to Ndlovu Camp where we'd be pitching tents to spend the night. The camp sits next to a watering hole, in which 3 Hippos floated while several Impala drank from its banks. We ventured out into the park (definitely pushing our small compacts to their limits on some of the dirt roads) looking for game, and managed to track down a decent selection of game, including warthog, Waterbuck, Nyala, Kudu, Giraffe, and several White Rhinos, a pair of which passed about 15 yards behind our car.

As sunset approached we headed to the watering hole to watch game trickle in. In addition to most of the game we saw on our drive, we also saw Blue Wildebeest and a very showy Ostrich. The highlight was a group of 5 elephants that emerged out of the brush to pass between us and the watering hole, before disappearing again. We had dinner by kerosene latern (the camp has no electricity) with a pair of African Grass Owls watching us from the rafters, drank wine around the campfire, and headed then to bed, scattering Impala as we walked.

The next morning I was awoken by a couple different sounds, one I'm guessing was some type of jackal (dog-like howl, not sure what else would make that noise at Hlane), and a grunting roar that was probably the hippos we had seen earlier at the watering hole. After spending most of the morning watching animals heading to the watering hole, we hopped in a safari truck and took off on a guided tour. Our guide managed to find a herd of elephants rather quickly that included a few younger elephants; a few times our heart rates raised when one of the adults would flare its ears and starting approaching our truck (unfortunately can't upload those videos yet). We continued to scour the park, looking for more big game, coming across our first Zebra for the trip. Finally, we came across a trio of rhinos, and it was time to hike. Our guide shut off the truck, grabbed his "gun" (actually just a stick with a balled end) and led us on foot into the brush for a closer look... while the picture to the right is obstructed by thorn bushes, it does a good job of demonstrating how close we were to these awesome animals (the bush was an arm's reach away). We changed position a few times (including once when a curious animal started walking our way) before the animals started working away from us towards the watering hole. Definitely an awesome experience, crouched in the middle of the thornveld with only about 20 feet seperating me from a White Rhino.

Overall, we had a great time touring Hlane. While the species diversity may be less in comparison to some of the other parks in the region, it is also a lot quieter, with fewer people. In addition, the rhino walk is an experience I'll never forget, and the chance to sit and watch elephants and rhinos stroll past a watering hole as the sun set with only a few others around doesn't happen at the bigger parks.

"This is Africa."

Took off early today for the first of several rural clinics we'll be doing with the VanderWals and the Luke Commission. While today's clinic was smaller than most of their others (meaning we only worked about an hour past dark, instead of past midnight), it was a good introduction to how they run their rural clinics; the more relaxed atmosphere also provided us an opportunity to visit two homesteads near the clinic site to peek in to a more typical rural Swazi household.

"Make" (pronounced mah-gay- SiSwati for "mother" and a nickname for any woman of appropriate age), at the center of the picture (the rest is the complete Boonshoft crew), led us around her homestead, where she lives with her husband, three of her children, and the three children of her husband's other wife (polygamy is a part of Swazi culture), who had abandoned her children. The family survived on the maize they managed to coax out of the tough red clay and grass mats she weaved (60E a piece, <10 US $) which took about two weeks to complete (her loom is in the picture on the left); her income is further compromised as she had to take public transport into Manzini (it took us 2 hours to drive), and could only sell what she could carry. The homestead itself was made of 3 or 4, with walls made of branches weaved around rocks, later solidified with mud, covered with a thatched (and often leaky) roof; a couple huts were designated for the 8 to sleep in, and another was used for cooking. Her homestead was fairly typical for the area (some better, some worse), and fortunately, her family was relatively physically healthy. We visited a second homestead nearby, which was empty except for one "gogo" (grandmother), sitting on the floor of her home, unable to walk to the clinic because of her asthma (audibly wheezing when we arrived); some of her family members were in Johannesburg working as well. She showed us around her hut, and even pulled out her Swaziland ID card, showing us she was 86 years old. As our car was too far for her to reach, we sent medicine back to her homestead with the local pastor.

After these visits, we climbed back up to the clinic; typically, they are run at a school, which provides several buildings for the operating of different stations. At this clinic, clothes and bandaids were given out to children, largely aiming to develop stronger relationships with the community. The real focus, however, is the medical clinic, which is run entirely by the VanderWal's staff in an amazingly efficient, organized manner. First, patients register, and the TLC staff fill out brief patient histories. From this station, they proceed to triage (where we spent much of our time); based on patient age, blood pressures and blood sugars are collected, as well as a rapid ELISA HIV test if requested. Next, they see Dr. VanderWal, where they are given an interview and prescriptions. Some patients may require an extra, private physical screening. Addtionally, patients are given HIV counseling, and HIV positive patients have their blood drawn for a CBC (cell count), chemistry, and CD4 count (again, measuring the "progress" of HIV in that patient). Once they have been treated and counseled, they proceed to the "pharmacy", and are given medications.

The clinic was truly impressive to witness; the number of patients served (even at this small clinic), is amazing; according to Echo, they screen more patients for HIV than any other operation or institution in the country (upwards of 120-150). Additionally, because of the remote locations, every piece of equipment (including lighting for after dark and the generators required to run them) has the be carried in by trailer over many kilometers of rough, narrow, dirt roads. The clinics serve an important role, covering a gap in care that would otherwise go unserved. In Africa, the most pressing problem (what am I going to eat today, where am I going to shelter my family tonight, etc.) continually takes precedence over more chronic issues (even if they are more dangerous); slowly developing health problems often take a back seat. For example, we saw a man with very large, bilateral, inguinal hernias; he had not made an effort to have the problem corrected because he had been able to survive with it to this point, while giving attention to other issues. Through the intervention of TLC, he was set up with an appointment at RFM Hospital with a general surgeon, as well as an account at the hospital (a huge bureaucratic hinderance in Swaziland), all on the dime of TLC. Furthermore, his travel expenses would be reimbursed. If he follows through (Echo estimated about 80% of the patients given this setup do), he would be saved from a potentially deadly emergency.

It's been a long weekend (our first great African adventure as an independent group... another entry on that soon), and another clinic awaits tomorrow. I've got many more stories to share about these clinics and their impact, and I look forward to writing more over the next few weeks!

"The treatment was stopped because the patient defaulted numerous times."

Less information, more reflection in this one, and to be honest, a little hesistant to post this entry. Chris and I did rounds in the pediatric ward this morning. While a lot of what we've seen has been tough to swallow, there was one case in particular that really hit hard today. At the end of rounds, we went into the Tb quarantine rooms with one of the pediatricians, where we saw two different patients. The first was a twelve year old boy, who weighed a total of 17 kg (~40 lbs), was severely malnourished, and battling numerous infections (some visible on the surface of his skin, others visible on CXR or blood counts). It's becoming a depressing pattern; usually I guess about 4-6 years under the actual ages of the peds patients I've met, with much of the country's children afflicted with stunted growth from malnutrition or disease. The second patient in the room was a little girl, about 10, HIV positive, who was hospitalized with Tb. According to the physician, Tb treatments were "stopped because the patient defaulted numerous times." With broken family support (the HIV problem has created a "generation of orphans" in Swaziland), repeated attempts to treat the girl's Tb had been interrupted. One one hand, continuing this pattern could potentially be quite dangerous, because it can allow the bug to become resistant to standard Tb treatments, exposing the population to an even more dangerous disease. At the same time, it's absolutely devestating to think of a child as a "patient who defaulted", a thought that completely violates any sense of compassion. With 3.5 more weeks left, including at least 5 rural clinics, I'm sure this theme will be repeated, but clearly and painfully highlights the fact that the HIV problem is not only about the individual patients, but also the crippling effects this disease is having on families, social structures, the economy, etc., allowing further proliferation of the virus with heavy human cost.

Hard to believe it's already been 6 days since we touched down! It has definitely been a whirlwind as we've gotten settled in, explored some of Manzini and Swaziland, and had our first peek at Raleigh Fitkin Memorial Hospital.

Friday was spent mostly taking care of business after our 24 hour trip. Trip went off mostly without any problems, except for a few stumbles at JFK when we ended up at the parking lot on the shuttle train (the furthest stop from the terminal). We blame poor signs throughout, and all agree it is the worst airport on the planet. Rest of the trip was a breeze, walking through customs with no issues (almost too easy) before taking off with Echo VanderWal into Manzini (we've ditched the rental car for now). Our first stop was Raleigh Fitkin Memorial (RFM) where we are staying. Our room is pretty nice, with two bathrooms (one currently has water), 4 beds in each room (most have sheets), and a kitchen/washing machine. In all seriousness, pretty comfortable, and we've certainly made ourselves at home.

Saturday we went with the VanderWals to an orphanage near Hawane, NW of Manzini. Again, the trip was beautiful; the landscape here is really gorgeous, with rolling, rocky peaks, and green trees and brush scattered on the brown (it's winter here) veld. The orphanage "fun day" was a blast... our team ("Green Land") won, thanks in part to some sack race heroics by Brad Scherer, who managed to recover from his stumbles into a graceful somersault across the finish line. Most of the participants (outside of the residents) were members of the VanderWals' church; interestingly, the church was founded as an extension of the orphanage, and is dedicated heavily to mission work in Swaziland. We attended church with the Vanderwals on Sunday, a much different experience than the Catholic masses I am used to attending. Afterwards, we had lunch outside, overlooking a ffield holding about a dozen Crowned Lapwings (bird... google it!). This country is awesome.

Monday was our first day in RFM; we've since spent the rest of week thus far in several different departments, following behind many different doctors. Monday morning we met with Dr. Costa, the student coordinator at RFM. He took us on rounds in the male medical ward; starting from the entrance, working towards the back of the ward, the patients become progressively more ill (the back two rooms sealed off, holding patients with tuberculosis). The first few patients weren't unlike anything you'd expect back in the US; a man with a seizure disorder in one bed, gastroenteritis in the next.

Pushing deeper into the ward, the patient population became much more representative of the HIV crisis crushing the country and continent. As we neared the furthest reaches the patients became thinner, weaker, and less responsive. Their infections seemed to come right out of our POD coursework: oral thrush, pneumocystis, histoplasmosis, and with just about every patient, Tb... almost all having wasted down to skin and bones. The last patient we saw, we'd later find out, had a CD4 count of 2 (for those not in medicine, this is the cell HIV destroys, and a count of 2 is extremely, extremely low).

Tuesday and Wednesday we have spent exploring more of the hospital, meeting new doctors and figuring out which of the physicians are better teachers. I've spent time in the outpatient department, which functions more like a walk in clinic; we've met a few pediatricians here who have been great, walking us through each patient, explaining disease and treatments, from HIV/AIDS, through skin and respiratory infections. In addition, I've had a chance to follow rounds through the malnutrition unit, learning about the two classifications they use and the treatments each require (fortunately, while on rounds today, many of these children were a day from discharge). I've also spent a good amount of time in the Emergency Department. Not unlike the two years I spent working there in the US, it's a lot of organized chaos, but the doctors have been pretty good about grabbing us to watch procedures or quizzing us on X-rays. I saw an abscess with a drainage that puts just about any I've seen before to shame, along with quite a few thoracentesis (mostly draining pleural effusions resulting from Tb). All 6 of us have had some pretty neat experiences, and seen a lot of diseases we otherwise won't back in the US (measles!).

This afternoon, Echo tracked us down in town to bring us to their home for a few interesting cases (when not running clinics, they treat patients there). One particularly intersting case was an HIV patient with what we thought was a lipoma, a benign adipose tissue tumor (skip to the enxt paragraph if you've got a weak stomach). After it was punctured, Echo forced our globs of grayish, color-flecked, proteinous tissue (I thought it resembled wet pocket lint); the best guess the VanderWals had (they'd seen one more like this) was that some sort of insect/worm had laid eggs, around which this tissue had developed (it wasn't vascularized like a lipoma would be). Fascinating.

As a unit of 6, we the majority of each day together. While each of us claims to have no cooking ability, we've pulled together some pretty decent meals. Picture to the left (mostly to let my mom know I'm eating well) is our first hack at it, with all 6 of us contributing to make a pretty tasty pasta dish. We definitely have settled into a pretty good group dynamic (not that that was ever in doubt); I'm really glad I'm traveling with these 5 people! We had our first adventure walking out of the hospital today to grab lunch and some groceries (most of the area is not too safe to walk in); had my first Stoney Tangawzi (ginger beer) of the trip.

That brings me to an end to this update; I'm going to follow shortly with another based on some of what I saw today. Tomorrow, we venture back into RFM, with our first rural clinic to follow on Friday (we're all really pumped), and Hlane Game Preseve over the weekend.

Greetings from Manzini!

Hey folks! We arrived in Manzini today in one piece! Everything is going well, getting settled in, will have more later. For now, please enjoy the view.

Next stop... Manzini!

Hey folks!

We take off in less than 9 hours, and will be on the ground about 24 after that! Hopefully this attempt at crossing international borders goes better than some of my previous attempts (if you haven't heard those stories... another time).

A couple quick facts about Swaziland- nestled between South Africa (NE edge) and Mozambique, Swaziland is one of the continent's poorest countries. The life expectancy at birth sits in the low 30s, largely contributed to the high prevalence of AIDS; with an adult prevalence between 25-40%, Swaziland has the planet's highest AIDS rate.

We are all very anxious to get going and excited about the opportunity to do work in Swaziland!