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.