After 27 hours, we finally landed in Dayton. The flight from US from Jo'burg was particularly long (17+ hours in the air), lengthened by about an hour and a half by a fuel stop on the west coast of the continent in Dakar, The Senegal. Customs and security was surprisingly easy, the only hiccup being comments and questions from TSA about our matching shirts (the finest threads downtown Manzini has to offer).

As we touched down, bags miraculously not getting lost, my trip drew to a close. The last month has been an unbelievable journey that, though I've tried, I really cannot truly capture with words or even pictures. Since first visiting Nairobi, Kenya, more than ten years ago, I've had an itch to get back to that continent; those who have visited Africa know the pull that I'm describing. Initially, I had planned on returning to Kenya, until a US State Department ban blocked my efforts; I am incredibly thankful for the opportunity that then arose with the trip to Swaziland. Looking back, I cannot imagine not having this experience. From start to finish, including the first days in Manzini, learning and observing at RFM, working with TLC, and our adventures in Swaziland and South Africa, it was the trip of a lifetime. I am grateful for each of the new friendships I've made and especially the opportunity to work with the Swazi people, most notably the TLC staff. The trip, as should be expected with any trek to Africa, was nothing like I'd expected or anticipated, but met and far exceeded all the expectations I had built up (which, as anyone around me between January and June could tell you, were exceedingly high). The African pull is only stronger now, and I can't wait to someday return! In the coming days, weeks, months, and years, I look forward to sharing these stories with you in person, and cracking into the many pictures/videos that the sluggish RFM internet connection wouldn't allow me to post.

Ngiyabonga!

Sam

Last rounds at RFM

With the clinics over, we spent some of our little remaining time in the wards here, squeezing out whatever we could before our final departure. Weekend nights are typically busy in the Emergency Department, so after clinic on Friday I headed down, and the three of us spent a chunk of Saturday night there as well (we've done similar visits throughout the trip). Monday we sat in on an internal medicine department meeting, and tracked a few physicians on their complete morning rounds.

With a few years in the ED under my belt after undergrad (and most likely many more in my future), I was especially interested to get into the RFM ED and see what it was like. Much like in the US, in the RFM ED I was able to see a wide variety of illnesses/injuries, of all ages.

• Lots of thoracentesises (insertion of a hollow needle through the back, into the pleural (lung) cavity to drain accumulating fluid) due to the very high prevalence of tuberculosis.
• Not many beds in the department, so many patients sharing beds (one bed, generally used for Peds, almost always had 2-3 children on it, often with IVs running) or benches (one was used as a sort of waiting/asthma treatment room, with sometimes 3 or 4 patients packed together, inhaling nebulizer treatments).
• Witnessed a patient drinking charcoal solution (for the treatment of toxic ingestions); while this is a standard treatment everywhere, it was interesting to watch her drink the solution like a frat brother chugging a beer; I've seen this same solution used dozens of times in the states and almost without fail, it only goes down with lots of coercion from nursing/physician staff, threats of nasogastric tubes, swearing from the patient, and a few times, the cup being tossed at the staff. Seeing this compliance was, therefore, fascinating.
• Manzini is dangerous at night, and bottles are effective weapons (and the weapon of choice). And drunk patients will profess their love for staff, regardless of country.
• Nursing tools in Swaziland include a heavy, 1 1/2" open ended wrench, wielded to crank open oxygen tanks.
• Uniform/dress was a little looser... can't say I ever thought I'd see someone suturing in jeans, an argyle sweater, and a winter cap.
• In both the US and Swaziland, police had a regular presence in the department. However, while in the States, the police usually kept their pistols holstered, while in Manzini, one officer walked in with an assault rifle hanging from his neck across his chest.
• Similar to the US, even had some "full hospital" problems; at one point, the female medical ward was full to the point that several meningitis cases could not be admitted.

Monday morning, we sat in on a weekly meeting with the internal medicine department. Admissions from the weekend on-call physicians were presented, as well as any movement in the medical wards (censuses, deaths, etc.). We also had the chance to listen to the physicians discuss some administrative issues facing the department. While a shift from the clinical focus that most of our time in RFM has, it was interesting to learn about the additional struggles piled on to health care workers here. After the meeting, we took a final lap of morning rounds in the male medical ward, as well as pediatrics.

In general, it has been hard at times to capture this trip with words that I feel truly justify the experiences that I've been lucky enough to have. This has been especially true about our time in the wards at RFM, made even more difficult because we were asked not to take pictures in the hospital this year. Each trip into "Cubicle 4" has been uniquely powerful; with the constant turnover, there are always new cases and presentations, and the general appearance of the patients is often difficult to see, most of them in what would be primes of their life (20s-40s), but bodies broken an atrophied, usually by HIV and/or Tb. Most blankly stare out of sunken eyes, minimally responsive to the doctors questions (if at all). The last patient we saw was a man in his mid-40s, breathing so labored that he was sweating from exertion, repeatedly asking the nurse for oxygen (which, at this point, was already turned on to the maximum level). A quick peek at a chest X-ray showed the cause; the appearance of a thick haze over most of the chest cavity showed that he had essentially one-third of a functioning lung at that point. The doctor explained that courses of antibiotic treatments (including anti-Tb treatment) had showed no results, and the likely cause was lung cancer. In Swaziland, pneumonia/Tb occurs at such a high rate that it is almost always at the top of the differential diagnosis list for pulmonary ailments and almost an assumed diagnosis (especially with any sort of pleural effusion on CXR, and rightly so based on the prevalence here), whereas in the States, lung cancer would be detected much more often (and would be potentially treatable). For this man, at this point, there was little that could be done.

We spent a few minutes discussing Tb treatment (and the challenges of) with another physician, standing on the sidewalk between two of the medical wards. The challenge with Tb arises largely from the nature of the disease; with a slow life cycle (divides at a very, very low rate) and the bugs ability to survive both extracellularly and intracellularly, it is difficult for drugs to be effective. Tb treatment requires a 6 month course of multiple antibiotics, and stopping short can allow recurrence of the disease if it has not been eradicated from the body; this often also allows multi-drug resistant TB (MDR Tb) to develop, rendering antibiotics ineffective against the pathogen. Many patients start their course, feel better (as the bug is subdued by the drugs), and as a result stop their medication. Generally, the bacteria is still present in low numbers, and comes creeping back. Patients, nervous about the diagnosis, tend to refrain from returning to the doctor, and wait until the disease has a strong hold, often to crippling levels.

While his insight into Tb treatment was interesting, there was a particular moment that grabbed all three of us. As we talked, two porters wheeled a bed past. I assumed it was a patient headed for surgery, or perhaps returning from X-ray, until it was next to us and we saw that the head was covered with a black garbage bag. Neither the doctor, nor the three of us, really broke from our conversation, as a sight like this is something we'd become used to in our month here. In the US, when I would transport the deceased, we used a special, covered cot, back elevators, and moved through the belly of the hospital to reach the "cold room" to avoid crossing paths with any visitors or other patients; here at RFM, this cot wheeled through an open, crowded sidewalk, with no effort to cover the body or hide what was being moved. The moment captured one of the overriding themes I've seen over and over again on this trip, bred largely from a skyrocketing HIV rate and a life expectancy lower than any other country on the planet. TIA.

Lost

With our trip wrapping up soon, Chris, Brad and I took one last adventure. Like just about everything on this trip, it was obviously bound to shift off course.

Early on in our trip planning, we'd come across Mlilwane Wildlife Sanctuary; though it lacks the complete "Big 5" (only home to Leopard... no Lion, Elephant, Rhino, or Buffalo there), its picturesque scenery and fantastic hiking make Mlilwane the most popular park in Swaziland. We took a taxi (also a new experience for the trip... we were all a little confused when our cab driver showed up with a friend sitting shotgun) about 30 minutes east of Manzini into the Ezulwini Valley. The cab dropped us off at the reception gate (a small building containing a desk where we paid the entrance fee and a small museum on the history of conservation in Swaziland), and the adventure began.

We split out from the reception gate into the park on foot; while there was no chance of, say, a lion popping out of the brush, since we spent nearly all of our time in Africa on safari in vehicles or with a guide, it was pretty thrilling to be walking down the hard red clay of the dirt road with zebra, impala, nyala, blesbok, and wildebeest in the plains surrounding us. In the distance, our destination, the "Rock of Execution", awaited us. In the distant past, according to what I found, those convicted of crimes against the king were marched (by spear point) to the top, and thrown off, plummeting to their death.

We should have known that we were in trouble from the start, when we struggled to find the first rest camp where we would be picking up our map. In our defense, the tracks are not marked, and with a Swazi accent, it's impossible to distinguish whether or not the clerk said to turn left at the "white" or "wide" intersection (and we came to some of both). After a couple gut decisions, we managed to stumble in to camp. We rented the map that showed the path to the top (which was only partially useful, and as we set out, the camp guide told us they'd send help if we weren't back by dark... turned out to be less of a joke than we thought.

Map in hand, we confidently continued our trek into the park. First stop was a large hippo pool, where we spotted a few basking hippos, as well as a few crocs and good numbers of birds. Anxious to climb, we pushed forward, entering a large stand of eucalyptus (to protect our manhood, I'll go ahead and pretend that the three of us didn't talk about how nice the air smelled). The habitats continued to shift as we walked, and we coursed through cool, wet forest, weaving through breaks between boulders and scampering up hillsides. As we moved up in elevation, the foilage reflected the much more arid conditions, with the land taken over by dry grasses and aloe plants.

As we became closer and closer to the top of the mountain, we encountered a number of animals at very close range, including nyala and impala. Nothing scared Brad quite as much as the Rock Hyrax we encountered (an example of the oversized hampster to the left); as we rounded a bend, it scampered off of a rock into the brush, which sent him jumping back into Chris and I with a string of words that probably aren't blog appropriate. Despite Brad's shaken nerves, we pushed forwards, coming to a split in the trail, and the peak of our adventure.

The guide down at the rest camp advised us that the hike would be easy, with a trail marked by "rocks with footprints on them the entire way". While we figured we were on the right trail, in the 2 hours thus far we'd seen maybe 3 of those rocks. We came to a split in the trail, directly under the cliff face of the peak. One branch, thick with grass and brush, headed directly under the peak, though we couldn't really make our where it eventually went. The other worked behind the mountain, though was much clearer, and similar to the path we'd been hiking. We chose the second path, until we began hiking down (at a good decline) for about 10 minutes, wrapping behind the mountain. Deciding we were on the wrong trail, we turned back to try the second option. When that trail became even more treacherous, to the point where we weren't even sure if it was even a game trail, we retried the first path.

We headed back down the decline we'd just deemed the wrong path, assuming it had to be the right trail, given the state of our second option. We continued beating down the mountain, now moving away from the peak, and nowhere near where the map said we ought to be (not on any marked trail actually, and likely moving into the northern section of the park, where a guide is required). Eventually, we stopped, and I offered to peak a little further ahead on the trail to see if it looked promising. Committing the cardinal sin of wildnerness hiking, I lengthened this peek to a 20 minute exploration, moving out of hearing range of Chris and Brad, as I continued hopping to each new bend (each of which actually looked promising). The jungle grew thicker, and flocks of birds started exploding ahead of me as I walked (at least I hoped they spooked because of me).

I started to get pretty nervous; while Mlilwane doesn't have most of the more dangerous animals, and the mountainside wasn't going to be hosting any crocs or hippos, the habitat looked great for leopard. At one point, certain that Brad and Chris wouldn't hear me if I yelled, I pulled my switchblade out of my pocket and opened it. Why I didn't decide to turn back then, I don't know (seems like a sign), and how I thought I would defend myself with the 3.5 inch blade against whatever I thought was going to attack me, I have no idea, but it made me feel a little safer (though the most likely outcome was tripping and accidentally knifing myself). Eventually, I gave up and hustled back to Chris and Brad, and we again returned to the trail break. As we walked, the jokes we'd been making about having to spend the night on the mountain quickly disappeared as we became more and more nervous about our situation.

While Mlilwane doesn't have many predators, it does have its share of poisonous snakes; risk was low, since snakes are not very active this time of the year, but the tall grasses and thick brush we were now essentially wading through seemed like the perfect places for snakes to hide (and I HATE snakes, and I wasn't alone in that thought; at one point, Brad brushed a shrub, which made a hissing-like sound against his backpack, and he jumped back into us for the 2nd, but not last, time). After about 20 minutes of swimming through brush and monkeying over boulders, we came to the first sign that we were maybe on the right path: a rickety plank bridge, tacked to the side of a cliff, with a healthy drop beneath it. I'm not sure how it was supported, and I was really glad to be across it. The trail continued like this, thick brush, boulders, and the occassional rickety bridge, for about 45 minutes; determined to get to the top, but running our of daylight, we kept pushing.

Finally, we hit a sign that pointed to the summit. After another 15 minutes of heavy hiking, sometimes climbing up rock faces on all fours, we reached the peak. Exhaused, we sat on the edge, gobbled down PB and Js, and punished whatever water we had left. The hike was completely worth it (and the extra kms we added as well), as the view was spectacular; with the rock falling away on three sides (in the picture to the right, the brush visible beneath me are trees... it is quite a drop) the valley opened up on all sides of us, with the hippo pool visible in the distance. Swaziland's landscape is gorgeous, especially this time of the year, with brown and yellows of dried grass broken up by patches of green plants and trees, covering a very rugged horizon; the view from the Rock of Execution really captured that. With our time drawing to a close, we all thought it was a fitting end to our time here.

With only a few hours left until dark (the hike, from the main gate, took about 4.5 hours with our detours), we scampered back down the mountain. Obviously, the going was a lot quicker on the downslope. On the way down, we had a few good, close encounters with animals. Around one bend, a gorgeous female nyala was standing in the middle of the trail. We walked very slowly to pass it, and it tolerated us, continuing to feed at less than 10 feet while we watched. Soon, we made it back to the hippo pool. At one point, the trail curves down by the water; Brad, about 15 feet ahead, again turned, this time, running back towards us yelling. Chris and I both crouched, ready to react to whatever (we assumed, based on his reaction) was charging towards us (hippo?). It took us a second, with the trail clear, to make out the crocodile basking (peacefully) on the bank (oddly, this, even with the most dangerous animal, is the only of the three startles that we give Brad any flak for, and we do need to give him credit for being in front at all three of these points). The croc was a monster, looking to be at least 4 M in length. Naturally, being stupid, 20-something dudes, we crept closer to the beast to pose for pictures.

Eventually, we made our way back to the rest camp, were we turned in our maps, grabbed some more water, and rested our legs and backs while watching another hippo pool (this one packed with birds, including a heron rookery). Worried about the approaching dark, we started on the last leg of our walk, walking through the same woods and fields, filled with wildlife, while the sun sank behind the mountain we'd climbed behind us. Another (mis)adventure in the books, we taxied back to Manzini.

From the dark end of the street, to the bright side of the road...

Today marked the end of our 4th week in Swaziland. While it feels like forever ago that we first landed in Manzini, I can't believe our trip is winding to a close. The last 4 weeks have flown by, but each day has been packed to the brim with activity and experience I'm trying to keep up with and process. We headed east this morning for our final clinic; it was one of our closest (less than an hour drive) and by far our shortest (we were pretty much packed by dark, ~ 5:15, while some of the other clinics have gone past 11 and we didn't get back to Manzini until around 2 AM). By the time the day wrapped up we'd still tested right around 100 Swazis for HIV, and like each clinic (and really every day here), it had its own unique twists.

Things were a little chaotic from the get-go, with the school having a game day today; when we pulled up, we could hear vuvuzelas blasting around the yard. Following a rather short pediatric screening (maybe 70 kids), Chris, Brad and I took in a game of netball (we decided it is best described as a cross between basketball and ultimate frisbee) behind the school. It actually looked like a lot of fun, but to our dismay and despite our best efforts to look like worthy competitors, we weren't invited to play. Things actually got pretty intense, with fans from each school lining the baselines and repeatedly breaking out very organized song and dance routines (as always, I've got video).

Similar to the clinic Wednesday, our number of positive HIV test results seemed to slip below the average rate we'd seen, down to maybe ~15%. Before the clinic fired up, we were discussing on the bus how easy it is to forget what these tests actually represent; after collectively performing hundreds of tests over the last month, it's easy to distance yourself from the weight these results have for our patients (keep in mind that we don't deliver the results to the patients ourselves, and in general, often lose track of which patients we've tested were positive or negative simply because of the sheer number we may see in the hours we spend in triage). At the same time, each time a child (or family) step up to be tested, your heart picks up, and a lump builds in your throat, and I will admit to a feeling of uneasiness, even fear with each finger prick. Unlike the many adult tests, I never forget the face that matches the number on these tests, and find myself continually peeking into collection box, hoping I see only a single line (indicating a negative result). A negative result provides an instant rush of relief, but the occasional double line can be crushing (as mentioned in my last entry, a single pediatric positive can wipe out any positive feeling about an otherwise "good", low day). Today's clinic had a few different kids test positive, and while we are glad to be aware of their status so that treatment and monitoring can begin, the potential reality of their future can be disheartening.

Perhaps further frustrating are parents who pull their children through the clinic, while declining to have them tested, even if they may be at risk. My heart sank today when I took a sample from a young mother with a baby wrapped onto her back not more than a few months old. Through a translator, the mother ("make", pronounced mah-gay) made it clear she did not want her child to be tested (not the first time this has happened; many Swazis are afraid of a positive result and what it might mean, and some are willing to live with this ignorance rather than solidify their status). After she walked away, I checked her result; positive. Assuming she was positive during her pregnancy (not really a stretch), there was about a 25% chance the child was also positive. I did not see the pair after they left our room, and it's possible that Harry or the HIV counselors could convince her to test the child soon, but the knowledge that this child was very possibly infected but not being monitored was, at best, extremely frustrating, and at worst, angering.

While on this topic, I should point out one of the brightest spots in the Swazi health care system, the "Prevention of mother to child transmission" (PMTCT) program. In Swaziland, anti-retrovirals (ARVs) are provided to all Swazis (money provided by The Global Fund) when their CD4 count drops below 350 (highlighting how unfortunate it was when this testing ability was temporarily lost when we first arrived!). An exception is given to expecting mothers. Regardless of CD4 count, they are given access to ARVs, until they complete breastfeeding. It should be noted that this used to be a controversial program; frightening, but not very long ago (within several years even) it was widely believed that it was better to allow HIV positive mothers to carry children without taking ARVs, as it was better that the child have HIV and suffer the fate of the mother, rather than continuing the proliferation of AIDS orphans in the country ("shocking" doesn't even begin to cover the feelings this stirs up, but it does highlight the challenges that some widely held, much-misguided attitudes have thrown in the path of progress). That attitude has (fortunately) waned, and this program has been quite successful in preventing the spread of HIV from mother to child.

As with all clinics, there are always surprises; this time, an SUV carried in 3 lame Swazis for treatment. This provided a new challenge for us, negotiating the crowded back seat of a Land Rover to test vitals and HIV status. TLC is involved with a program that donates hand-crank powered wheelchairs to those in need. The wheelchairs resemble off-road tricycles, and provide mobility and some independent to those who would otherwise be without (case in point, these three patients were only able to go to the clinic because a TLC partner picked them up). The wheelchairs are assembled on location, and today, we hustled to put together three of them (I hadn't touched a drill since leaving WBL last summer, and it felt good to have one in hand again, if only for a few moments). The wheelchairs are presented in a ceremony in which the new owners are instructed to take care of the chairs, regard them as theirs and theirs only to use, but to return them to the community when they no longer needed them or passed on; the wheelchairs also come with a number of spare parts for repair, lengthening their life. Prior to the ceremony, each of the patients were carried across the dirt yard and placed in their new chairs, and after Harry's presentation (translated by Sipho), our new motorcycle gang (picture to the left) spun their wheels for the first time, cheered by the surrounding crowd (except for the group of kids who had to flee as one patient learned to better handle the vehicle). I've been frustrated at times being confined to a few walkign destinations in Manzini. I can't even begin to imagine the way these patients must feel with the lack of freedom or independence their conditions place them in, but the smiles beaming from each one of their faces as they wheeled past was personally one of the more powerful moments I've witnessed at these clinics.

The clinic ended on a particularly positive note; as we prepped to roll back to Manzini, a film crew working in partnership with TLC today stopped to interview one of our patients. I caught part of the interview, and Echo filled in the rest of the details. The patient had once been a professional soccer player, but since contracting HIV, his once strong legs had atrophied, and he had lost his wife and son to the disease. For years, he saw a traditional healer, who told him his illness was due to a curse from those jealous of his athletic success. Once he was diagnosed with HIV, he started on ARVs, and reported feeling much healthier since, but was concerned about his remaining sons status. Pumi, one of the TLC staffers, performed the test on the spot on the boy who couldn't have been older than 7 or 8... negative :).

What a Wonderful World...

I've always enjoyed following along the travel blogs of my family and friends, but writing one has definitely been an interesting experience for me. I certainly enjoy sharing stories and the few pictures I can upload. At the same time, I've always been a very private person, saving my most intimate feelings and emotions for private conversations; trying to express what has been at times a very profound and spiritually involved trip has proven challenging, trying to both overcome my own hesitations to broadcast my thoughts while also attempting to find the text to do these experiences justice.

I found out last night that my grandmother passed away on the 4th. Those that knew Mary Corbo know that she was incredibly unique, with a larger-than-life personality surpassed in size only by that of her heart. To her last day she lived life to the fullest and on her own terms (a quality that I will always look up to her for); I know that we'll be telling stories about her for a long time, and I look forward to passing her legend on to my children someday. The same time that I heard she had passed I also was told that my Aunt Carolyn kept her updated on my adventures; it gives me immense comfort to know that even though I won't be able to recount this trip to her in person I was able to share this experience with her through what I've written, and so I am eternally greatful that I've had the chance to write.

Grandma Mary loved the Louis Armstong song, and it very much captures the lens through which she chose to see the world... here in Swaziland, while a dark shadow has been cast by disease and struggle, Mary would no doubt see the light piercing through, marveling at the work done by many of the people I've had the pleasure of meeting and working with or the kindness that seems to ooze out of Swazis seemingly universally. And I think to myself...






It has been a busy start to our last week here. Graham and Angeline departed Tuesday, so Brad, Chris and I are all that remain. It is a particularly busy TLC week, with three clinics to close things out. With several clinics under our belt, we've become used to the routine, but as has been the theme in Africa, every seemingly routine event tends to have a twist. Each clinic brings new twists and fascinating pathology, whether discovered in pediatric screenings, the adult clinics, or even the trek home (apparently we've now had a complete TLC experience, after helping manually rotate a loaded down trailer 180 degrees on a dirt road on the side of a Swazi mountain). At the last clinic, we saw a sharp decline in the rate of positive HIV tests we performed, dropping from what seemed to be about a 25% rate down to maybe 5 or 6 positives among the 150 or so tests we performed. At the same time, a positive test result in the case of an 11 year old girl quickly sobered any good feelings about what was perhaps an isolated pocket with a low rate or even just an inaccurate representation of the local population at the clinic. The impact the disease has on children here is most frustrating, whether the infection of an innocent child passed down from the mother, or the growing population of AIDS orphans (it's estimated that the 20% of the Swazi population will be made up of orphans under 17 by the end of this year).

Last week, a group of undergrad students joined TLC for a month; their arrival has increased the triage workforce, and I've largely been able to take advantage by spending more time roaming the clinics and learning more and more about the TLC operation; with each clinic a new thread to the TLC network seems to be revealed; it has definitely been very interesting to learn how this organization has been able to set its roots and grow, as well as where it is headed down the road.

While the medical care problems of Swaziland can be neatly listed or plotted in bullet format, they are best understood through the examples we've encountered through the patients that we've met on the road here. It is their personal stories and challenges that more vividly demonstrate why the HIV rate is so high or why life expectancy is hovering in the low 30s, lowest in the world. At Monday's clinic, we saw an example of Kaposi's Sarcoma on a patient's 2nd left toe, slightly swollen, looking like it was completely covered with small warts. Eventually, this cancer (caused by a herpes virus) could spread further up his leg. Kaposi's is an indicator of Stage IV HIV (and is AIDS defining) and is rarely seen outside of the HIV+ population; this patient was in urgent need of chemotherapy to stop the spread of the cancer. In Swaziland, this is available in Mbabane, the capital, about a 30 minute drive from Manzini, but an even greater challenge for this resident or rural Swaziland. Over their 5 years here, the VanderWal's have observed and networked across the country, determining which facilities can truly aid their patients, and by building relationships, been able to establish themselves as valuable advocates for the patients they meet in the field. For this patient, they were able to schedule appointment at a new clinic (not as easy a switch as one might think), which ran a monthly shuttle bus to Mbabane specifically for chemotherapy treatment. Without an outreach effort like the TLC mobile clinics (and their networking capabilities) this patient would slip through the cracks (though with the reluctance he showed initially regarding his HIV status and treatment, this is still a very real possibility), and in Swaziland, where the safety net is so thin, he would be part of the norm rather than an unfortunate exception. And so the struggle continues.

Over the last week, I've also had a chance to follow a new physician on morning rounds throughout the hospital. He has been an excellent and willing teacher (he even called another ward to try and track the three of us down this morning). We cannot take pictures inside of RFM, though I'll do my best to provide a description of the conditions in the hospital we've called home for the last month.

Each medical ward of the hospital (female, male, and pediatric) is broken down into 4 seperate cubicles, plus side rooms, with each housing patients meeting certain requirements. The first two rooms are open to the rest of the hall, including the nurse's station. The 1st houses acutely ill, non-infectious patients (diabetes, hypertension, CHF, etc.). The 2nd, seperated by a glass wall, holds patients with non-pulmonary infections (meningitis, sepsis, etc.). The 3rd and 4th are walled off, holding patients with pneumonias (and especially tuberculosis). 8 patients are crammed into each cubicle, with just enough room between each bed for one person to walk between. The beds are metal frames (while the chipped paint adds a nice "vintage" look, it certainly doesn't inspire any ideas of cleanliness about the facility) topped with thin matresses, and pillows are usually replaced by a folded sheet or blanket. Temperature control is another issue, with poorly sealing windows (if they close at all). Patients are piled under blankets, but considering I've spent probably half the nights here fully zipped into a 15 degree down bag (it gets into the 40s at night... it's winter), I'm assuming the patients aren't that well insulated. The wards are occupied by more than just patients; a pair of cats that call female medical home (not making this up... one brushed my leg today, and two days ago I watched another playing with a food scrap before sliding into a half-filled bedpan on the floor).

What RFM lacks in facilities (which, I should mention, have been improving over the last several years), it definitely begins to make up for with a number of quality physicians. Often, it appears as though the physicians here are forced to practice medicine with a hand (or two) tied behind their backs. Already lacking many of the standard technologies used in the US (for example, we had a patient today with a suspected CVA, but with no CT scan in the hospital, no way to confirm), temporary lapses in even the most basic health care tests plague the hospital (I've previously mentioned a CD4 reagent "outage"... currently, RFM is unable to perform blood chemistries because of a machine issue). I've been continually impressed with the perserverance of the staff here, who seem to battle forth and make the best of whatever they have available, even when the going gets tougher and tougher.

While death is all around us in Swaziland, we've (perhaps oddly) had little direct experience with it. Over the last week, I've been hitting the same wards, and this repetition has made it obvious which beds are empty because of discharge, and which are empty because the patient has expired. We saw two patients in the female ward Tuesday whose beds were empty today. One, a 37 y/o woman, was unresponsive, but breathing very rapidly due to acidosis. Initially, DKA was suspected, but the patient did not respond once sugar levels dropped, and the physician suspected that her acidosis was renal in origin... but given the inability to take blood chemistries as mentioned above, kidney failure was impossible to measure. The second patient was younger, in her mid-twenties, with large pelvic masses seen on ultrasound that again, were likely causing kidney failure (and again, no way to test without chemistries). When we left her on Tuesday, she was barely responsive wither blood pressure was hovering at 70/50, and as a result I wasn't surprised when her bed was empty Thursday morning.

Our most direct experience came in the male medical ward. While doing rounds on new admissions (Tu/Thurs; complete rounds are performed on Mondays, Wednesdays, and Fridays), we approached a bed in the corner of the last cubicle (sickest Tb patients). The patient looked much like many of the patients in the ward; thin, skeleton-like bodies with cheekbones protruding, minimally responsive, eyes glazed. As we neared, I got the sense something was not right, and before I could be sure the physician turned to the nurse and said, "Sister, I believe this patient is dead." A quick check with the stethescope confirmed his suspicion. He offered a sympathetic apology to the head nurse, and after a quick note, we turned and left.

As we walked out, I couldn't help but reflect on the scene we were leaving behind. The patient, 41, had walked into the hospital emergency room at 4PM the day before complaining of a loss of appetite and a cough, with jaundice showing in his eyes and a diagnosis of HIV. Sometime between then and 9 AM the next morning, he'd died tucked away alone in the corner of the ward; without the benefit of monitors, he'd slipped away unnoticed (not as though it could have been prevented I should note), until being 'discovered' on rounds the next day. In the corner of the crowded ward the patient's body remained, face still exposed, staring at the ceiling, no curtain blocking him from the view of the rest of the ward, no discussion of next-of-kin to notify. I can't quite place my finger on the feelings it brought up in me. With a few years in the emergency department, I've had plenty of experience with death, even cases much heavier in tragedy than those I've encountered here, but this case in particular is one I think I'll always carry with me.

I realize this is a perhaps bizarre ending to a post entitled "What a Wonderful World". The circumstances in Swaziland can be overwhelming at times, even for someone who is just observing. I have mentioned how privileged I feel to have been given the chance to work among the members of TLC; these feelings certainly extend to the professionals I've worked with at RFM. Given the uphill battle they face and the obstacles constantly thrown in their way, I am extremely impressed with and inspired by their abilities to continue their fight every day.

Blood Brothers

Squeezing in another entry on the heels of the SA adventure in an attempt to actually be close to "caught up" on our trip. Didn't make sense to squeeze it all together, given the length of the last entry and the very different subject material. The last couple days, we've gotten back to the medical aspect of our trip, with rounds at RFM, another TLC clinic, and some weekend work at the VanderWals, giving us a small glimpse of what goes on behind the scene on an "off" day.

Thursday was a particularly good day at RFM, and I was excited to be back on the floor. Generally, rounds run at the same time, and if you are lucky you catch one set before heading to the outpatient department or emergency (both very interesting and great for learning, but rounds are invaluable learning experiences). Thursday I lucked into rounds in the male medical ward, gaining more exposure to HIV, Tb, meningitis... while making a new physician contact in the process. While our doc took a tea break, we split for the pediatric ward, finding Dr. Gedahun, a very good pediatrician, who had just begun. A lot of the pathology in this ward is pretty similar to the US (and generally less severe than the adult wards)... lots of rotavirus, some pneumonia, though there are many cases intensified by the presence of HIV.

Of all the areas of RFM, male medical has been personally been one of the most impactful. The VanderWals, early in the trip, talking about one of their staff members, mentioned how few healthy adults (especially men) you see in the Swazi population. While you can definitely pick this up among the general population, it's incredibly clear in the hospital inpatient departments. Whereas in the US, a heavy fraction of hospital admissions is composed of the elderly, whose bodies may be showing the signs of 70-80+ years of wear, the majority of the Swazi hospital patients are in their 20s, 30s, and 40s, nearly all positive for retroviral disease. In a frighteningly short span (with no sign of slowing) HIV has rapidly drained this country of this group. One patient in particular hit this point home. He was my age, and unable to lay in bed or sleep (actually the first patient I've really heard complain here, and it was mild at best) because of overwhelming chest pain when he would do anything except sit up tucked into the fetal position. The doctor showed us his chest X-ray: severe cardiomegaly secondary to retroviral disease (mechanism unknown), which would probably continue to deteriorate and take his life; over the course of the night he'd started coughing up bloody sputum (he was also Tb+) and would spit it into a bedside pan after each wincing cough while we reviewed his case. His case wasn't particularly unusual, with the ward (32 beds) full of cases very similar to his in underlying illness (HIV) and age (young), differing only by the secondary infections that were currently ravaging their body.

Friday we headed to our fourth TLC clinic. This one was rather close to Manzini, with highway taking us particularly close, but the last part of the drive, north around a mountain range and then back behind them, heading south (all dirt roads) made it a much more remote location. This was a particularly smaller clinic, though a flatbed truck hauling in mkhulus and gogos (elderly patients) helped populate it. Overall, this made the crowd much older, and we all noticed a decrease in the rate of newly HIV+ patients as a result (~10% vs. the 30% we've become accustomed to at the other clinics). You pull positives wherever you can grab them.

We had a chance to listen to one of the TLC staffers give the community education talk that opens each clinic as another staffer translated for us. The talks, while covering important talking points outlined by TLC, flow as an open conversation with the community, answering their questions and concerns about the illness. This helped to highlight many of the misconceptions that Swazis have about the disease (which add immensely to the spread of the disease:

• HIV was brought to Swaziland by Americans.
• HIV can be transmitted by touching an HIV+ individual, or even by looking at them. TLC staff dispelled this rumor and gave advice on how to safely care for HIV patients (where gloves cannot be accessed, using a plastic bag without holes can suffice).
• Doctors performing circumcisions use the foreskin for soups or spices (actually a pretty common belief in much of Africa). Circumcision greatly reduces susceptibility (and therefore transmission to others) of HIV for multiple reasons (by ~60% per the WHO), and there has been a big push across Swaziland to promote circumcision (including a brand new surgical center dedicated to the procedure at RFM).

Again, the work of the Swazi members of the TLC team to lead the charge against HIV in their own country continues to impress me. Between patient registration, translation, pharmacy distribution, HIV counseling, and the work we'd see after the clinic (an "off day"), they put a serious amount of fuel and energy into the TLC machine. Fighting HIV in Swaziland is an uphill battle; community misunderstandings compounded with isolated communities stress a nation already struggling with a lack of resources (for example, when we landed on the tarmac, there was no CD4 count medium available, save for a few small private labs... it's impossible to tackle HIV without it). Fitting that while listening to my iPod while typing, "Blood Brothers" came on: I'll keep movin' through the dark with you in my heart... my blood brother. The Swazis we've worked with at TLC keep trudging forward despite the toll the disease is taking on their country, their friends, and even their family.

Saturday, we spent a little bit of time at the VanderWal's house and did a little bit of work while the team recovered from Friday (cleaning off the supplies and equipment... a "leak" in the trailer + the African dust did work on their equipment) and restocked for Monday's clinic (they don't work Sunday). We filled eyedropper bottles (much cheaper to make your own with saline than buy individual bottles) and made packets of oral rehydration treatment (really just salt and water, homemade... again, much cheaper). All of the prescriptions are given labels in SiSwati with simple, clear instructions.

We also had the chance for a little experimentation, sparked by a pair of cases at the previous day's clinic. We'd seen two particularly bad foot ulcers; with poor hygiene, and particularly limited access to health care, a lot of wounds can lead to further, deeper infections and complications like osteomyelitis, or the need to amputate. Echo had been forwarded a study outlining the merits or a sugar-iodine treatment for wounds, which showed suprisingly promising results for such a simple treatment. Application of non-sterile, granulated sugar (what you put on your Wheaties) along with providone-iodine proved to be anti-bacterial and anti-fungal, induced granulation tissue (necessary for healing), and nourished developing epithelial cells at the damaged site. As a result, even some of the worst wounds studied (many had failed to heal originally despite exhausting all other known methods of stimulation) recovered, even exceeding results seen with standard methods.

Using the article, Echo had us concoct our own batch. We played with different ratios of sugar, betadine, and vaseline, until we had a paste about the viscosity of peanut butter, thick enough to stick to wounds but thin enough to seep into wound crevices. We copied down the recipe (to make 3 L batches) and filled up about 2 dozen 100 mL specimen cups to begin distributing at clinics. With limited follow up ability, and only about 10 days left on our trip, we won't be able to see any results, but Harry and Echo do plan on tracking the results as best they can, and I am excited (and hopeful) to see any positive results (first patient to the right, on a cut to the 2nd digit... pt already reports improvement, though proliferative beard growth may be a side effect). Definitely bush medicine!

The rest of the day is only notable for one reason... we walked to dinner at a nearby restaurant, only to find it covered with American flag decorations and two blow up pictures, one of Barack, and one of Michelle. Odd in Swaziland. Happy Birthday America.