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).
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.
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