Stories from Swaziland

One year on

2010-01-01T01:31:00.000-08:00

This Sunday will mark a year since I have returned from Swaziland. I still think of that God-forsaken place every single day.
This year has been difficult for me on so many levels. I found myself crying when seeing African people walking down the streets with babies tied to their backs. I found it difficult to adjust to my new work places where the demands and expectations were so different to what they had been in the 6 months prior. I had trouble consolidating just what the experience meant for me and what role it would play in my future. There were many times when life just seemed so complex and complicated that I wanted to jump back on a plane and return to Swaziland where there was no television, no radio and where the simple act of dropping in on my neighbours was customary. I remember being delighted in the opportunity to take a car to Manzini or simply finding ingredients to making a good meal. I remember being with my friends who accepted me warts and all and would drop everything in a moments notice to spend time with me. I remember dancing to Motown music, laughing until I nearly wet my pants and dinner-time conversation that would have us laughing one minute and then crying the next.
And then I would remember all the dead people. I remembered the paralysing frustration I would feel when I would watch my patients suffer and there was little I could do. It was like hitting my head against a brick wall- every single day. I remembered little Noah and the fact that he represented all the little babies that died everyday. I remembered running out of medications, not having emesis bowls for my patients to vomit in and not having narcotics to ease their pain. It’s those memories that would occasionally keep me awake at night or randomly lead me to tears.

I was lucky enough to meet Judi in the first few months of my return. She’s a social worker who often counsels volunteers who return from missions with the Red Cross. Judi was able to “normalise” what I was feeling and was able to give me perspective and guidance on how to manage my myriad of emotions. I think she’s the smartest person I know and I am so grateful that she somehow managed to come into my life. One of the hardest things about returning from experiences like mine is that it can be terribly isolating. There are few people who truly understand what the experience was like and what it’s like to return. I have a friend, Ruth, who’s worked for the Red Cross in Sudan. We don’t talk often but I was struck by her comment that when you return from an overseas mission, you are surrounded by all your friends and family again but you just feel so damn lonely and I have to agree, the loneliness at times can be overwhelming. Since my return, I have devoured copious amounts of books written by people who have returned from similar situations and I have taken great comfort in knowing that my post-return emotions are very similar to others.

I have to admit, the blog did assist people to understand my experience in Swaziland. I am amazed by how many people followed it- literally people from all corners of the planet and even people I have never met.
Whilst I kept the blog, I also emailed friends whom I was particularly close to. One person that I was in contact with almost daily was a man who I had been sweet on for about 10 years. We shared mutual friends and a mutual career path and I had an enormous crush on him but it was unrequited and I never thought myself worthy enough of his attention. I had lunch with him the day before I left for Swaziland and then I was pleasantly surprised to hear from him during the time I was overseas. Our friendship certainly blossomed over email and I found myself confessing things to him that I wouldn’t put in the blog and his daily emails gave me the strength to carry on when things got really tough. He was the first person I saw when I got back to Australia and from there a lovely romance evolved. As I had mentioned previously in this blog, I was 30 and had not had a real relationship, so when all this developed, I thought I was the luckiest girl in the world. In my mind, this man was my “reward” for all that I had gone through in Swaziland. I was happy and I was enjoying life. It all ended rather abruptly and unexpectedly 5 months later. I think he was more enamoured with the idea of “Swazi Mel” rather than the reality of “Aussie Mel”. Trouble is, they are the same person, it’s just that I was an ordinary person in extraordinary circumstances and I was always going to appear more exciting, more confident and a little more special in Swaziland than I ever was when back at home. This time last year we were in daily contact and I was telling him my deepest thoughts, now, only one year later, he can’t even look me in the eye across a crowded conference room. It doesn’t matter how smart you are, there are still times when life simply doesn’t make sense. My heart still aches on a daily basis and I have to admit there is part of me that feels that someone will only think I’m special if I go and repeat what I did in Africa. This is difficult because going back will require a lot of sacrifice on my behalf and then I may just end up having my heart broken anyway.

I stayed with my parents for about 6 months and then I moved into my own apartment which I consider to be my ultimate sanctuary. I love it here and I live close to some friends who have been enormously supportive since I have been back. Nancy has been my rock here in Australia and I’m sure I would have been a lot more lonely and tormented if it had not been for her kindness and unconditional support. I’ve also been close to work and the commute time has been minimal. I have worked in two places since being back and although I have lost my passion for medicine I have been blessed to meet some incredible work colleagues who have really embraced me and made my life richer. They have been extraordinarily tolerant. I often find myself saying “You know, back in Swaziland…..” and they patiently listen as I rant and rave about the injustices that exist on our planet. This year, I recreated my Thanksgiving experience by having about 10 people over to celebrate. I cooked a turkey (not slaughtered that day…) and a variety of other dishes. I made Kristin’s unusual sweet potato dish and Courtney’s pumpkin pie and they both were a hit. Whilst the environment was largely different from Swaziland, the warmth and kindness in the room wasn’t that much different.

I have also been blessed to continue my friendship with Courtney. She’s my best friend in California whom I’ve known for 24 years . We email each other every day and I don’t know how I would have survived this year if it wasn’t for her friendship. She and her family came to visit me for the first time in August of this year and we enjoyed a whirlwind visit together. She is expecting her second child in February and I will go over to visit a couple of months later. She listens patiently as I ruminate on all my experiences in Swaziland and what has happened since getting back and she truly is a shining star in my life.

I was also lucky enough to spend time with my friend Anna (from Ireland). Anna, her partner Andrew and I spent some time up in Cairns, Port Douglas and Cape Tribulation earlier this year. Anna’s courage and determination in the face of adversity continues to be a source of inspiration for me.

I am also in regular contact with Kristin and Andrew (Peace Corp). They are still in Swaziland and will be there until July. They have accomplished amazing things during their time there. They are now living in a different place (without the dreaded latrine) and Kristin has been working closely with the Nursing School at Good Shepherd. She has been working on developing a new curriculum and has introduced computers to the school which has just revolutionised the learning process and invigorated their enthusiasm. The nurses idolise her and I am sure she has inspired them all and hopefully taught them something that will improve standards within the hospital. Andrew has been working tirelessly on improving community links/AIDS awareness and has helped establish a soccer tournament which seems to be a useful platform to open discussion between men on HIV etc. I know that they are going to be my friends forever and I cannot wait to see them again soon.

Julia (nurse who worked for Home Based Care) returned to New York State in November last year. She found it difficult to find employment so she took a road trip across the country with a friend who was going in search of employment. They ended up in New Mexico and Julia met Marcus. They are now living together in New Mexico and Julia is working in a coronary care unit. I’m not sure that she’s particularly happy with the job and it wouldn’t surprise me at all if Julia suddenly packs her bags and heads back to the third world.

Jenny (medical student from Scotland) went back and finished her studies. She is now a fully fledged doctor. She got engaged soon after her return and will be marrying later in 2010. I’m hoping that I may get the opportunity to attend.

Susan (public health worker) has finished her time at Good Shepherd and is now back in the UK with her husband. She’s working on some public health project in England but again, I wouldn’t be surprised if she embarks on another African adventure soon.

Chris, from Cincinnati returned to the States and worked in a hospital on an Indian Reservation. She is returning to Good Shepherd in April and will volunteer 5 months of her time again- this will be her fourth mission the Swaziland. What an extraordinary person she is. She still manages to make me laugh- even via email.

You may remember Katharina and Frank- a German couple I had the privilege of spending time with during the early part of my stay in Swaziland. They both used to work for BMW and then Katharina quit her job as a nuclear physicist to take up medicine so that she could work in the third world. She’s near completion of her studies but here’s the exciting bit- Frank was so inspired by what he saw in Swaziland that he also has quit his job at BMW and now is working tirelessly to raise funds to build a hospital in the third world where Katharina will work once she is finished. They had plans to set up in Darjeeling but after a recent reconnaissance visit, they may choose somewhere else. Needless to say, they are keen for me to join in on their project and I am watching from afar as I know this couple are about to achieve incredible things and I may want to be a part of it.

Niel (paramedic from South Africa who I worked with at Swazi 1000) returned to Bulembu this year for another round of building houses for orphans. Again, they were remarkably successful and Bulembu continues to go from strength to strength. Niel is going to volunteer his services and expertise in 2010 and work full-time at the clinic we both worked at setting up last year. I know he will do an amazing job although I do admit to being a tiny bit jealous because I remember thinking that someday I would return to Bulembu as the community doctor!

I am in regular contact with Heather and Andy at Bulembu. I am lucky enough to receive updates and photos of all the orphans they care for. The group in their care whilst I was there have all moved on to the bigger household, but have been replaced by another group who are equally as cute. They do an amazing job and I’m pleased that my job here allows me to occasionally contribute financially to their good work.

So, where does this leave me? The truth is, I’m not sure. I mentioned earlier that I have lost a lot of my passion for medicine since coming back. I’m supposed to be sitting my specialist exams soon but the reality is, I’m completely uninspired to put the necessary hard work in. However, it only recently occurred to me that having my specialist exams over will put a few letters after my name and those letters could open a lot of doors for me. I have thought a great deal about what I should do with my life and if I had to describe what I would really like to do, it would be to divide my time between my extraordinarily blessed life here and a life where I’m working in some of the more poorer regions of the world. This is not easy to do but I have started to explore my options. If I was to sign up with MSF or Red Cross, it would mean that I would have to quit my job and lose income for the 6 months I was away. This works for some people but I’m not sure it suits me. However, I have recently found out that if I joined the Army Reserve, the army would pay my employer to get in a locum for the time I am away. I would only be deployed for acute disasters and probably only for about 3 months at a time. Whilst I never envisaged me working for the military, this may actually be a more suitable way of me satisfying both needs in my life. I have a burning desire to work internationally but I also love my country and the privilege and lifestyle it brings me. My friend Ruth has also imparted some wisdom to me, telling me not to rush things as there will always be poverty and need in the world.

So the year ahead will involve a lot of hard work and study as I prepare to sit my specialist exams. I will still keep a close eye on the situation in Swaziland as the place will never leave my heart. I suspect I will be back there someday soon. In the meantime I will focus on expanding my knowledge and nurturing my passion for humanity. Look out for the next blog “Stories from………( somewhere else)”

2010-01-01T01:24:00.000-08:00

The End

2009-01-22T02:24:00.000-08:00

All journeys must come to an end and this will be the last entry I make in "Stories from Swaziland".
I have now been back in Australia for almost 3 weeks and I am slowly adjusting to life back in this privileged country. I'm back working in an emergency department. The irony is that I'm working for 6 months in the private sector, so I am treating people who have every resource available to them and I don't have to think twice about ordering tests or prescribing drugs- their insurance will cover everything. No one has HIV and no-one has TB. My working environment is relaxed, pleasant and stress-free. I am surrounded by support and I feel nurtured and appreciated. Yet, if I had to be truly honest, I actually miss some of the mayhem I faced in Swaziland. I miss my patients who were so grateful for the smallest things. There were times where all I could offer was a hug and a smile and somehow that was often enough. I miss my nurses who drove me crazy most of the time but had hearts of gold and treated me with an almost "God-like" status. I miss walking into town and having everyone I pass smile at me and greet me warmly. I miss my friends terribly. I think of Kristin, Andrew and Susan everyday and often wonder what they are doing. I am in regular email contact with them and the other day, Kristin emailed me to tell me of some of the projects they have done recently and I actually yearned to be a part of it. They are doing amazing things in terms of educating their community about HIV/AIDS. Kristin has started giving lectures at the nursing school and I know she will inspire the nursing students and encourage them to learn more. I am so incredibly proud of them. Susan still faces the endless bureaucratic nightmare of trying to co-ordinate care for those suffering HIV and TB and I hope that she knows that I am supporting her in spirit whilst not being there in person. Julia and Chris are settling back into their lives in the States (with their gorgeous new President). Jenny (Scottish medical student) has just finished her medical exams and will start her first year as a doctor.
I was walking through a shopping centre the other day and I saw two young African children. I had to stop myself from going up to them and giving them a warm embrace. In Swaziland, the children would have instinctively run up to me for a cuddle, but here in Australia, children are taught to not be so trusting. I am still in regular contact with my friends at Bulembu and I am sent regular updates on all the children as well as photos to add to my rapidly expanding collection. Sometimes, during my more quiet moments, I think about all those orphans and wonder what lies ahead of them. I still cry randomly and my heart often aches for inexplicable reasons.
That being said, I have adjusted quite well and I'm not sure I've ever felt this happy, nor this comfortable within my own skin. I have this new-found confidence in myself that allows me to think that anything is possible and that nothing is too hard. I appreciate things now that before I have taken for granted. I am able to see beauty in the mundane and I am able to treasure things that others may see as unimportant. This is a true gift that only the heartache of being in Swaziland was able to give me.
People ask me whether I will go back and the truth is, the answer is yes- just not yet. I can't imagine going through the rest of my life without being able to touch lives the way I was able to in Swaziland. It was the hardest experience of my life so far, but that doesn't mean I will shy away from such difficult experiences again. I actually think I will be back in Swaziland sooner than I think. I have some special friends there and although it may mean using the dreaded latrine again, I think my Peace Corp friends will have a visitor sooner rather than later.
I cannot finish this story without thanking some incredibly special people in my life. Many of you sent me warm wishes, support and love in various forms, but there are a few people who deserve special mention:
Courtney- by best friend in the whole entire world. She set me up with the blog and made various adustments to it upon my request. She emailed me every single day I was in Swaziland and her regular contact provided me with comfort that is simply indescribable and will not be forgotten. I think some of my "adventures" caused her quite a bit of angst at times and she has asked me to never embark on this type of thing again, but the amazing thing about Courtney is that her support is unwavering and no doubt will continue on the next crazy mission I undertake.
Mum, Graeme, Dad and Rachel- thank you for encouraging me to step outside of my comfort zone and refusing to let me give up. Thank you for still seeing the special side of me despite the fact I am incredibly "different" to every other 30 year old you know! Graeme- thank you for the 200 tea bags, 6 kilos of coffee and 3 litres of hand sanitiser that you went to such effort to send me. I never got around to using it all, but rest assure, there are many others who are still appreciating your efforts!
Anna from Ireland- despite your own difficulties, you were still able to empathise and encourage. It certainly was fate that brought us together again and I will never forget the support you showed me.
My friend Adam- you patiently listened as I described in graphic detail my various changes in bowel habit, my fears that my skin was infested with bugs and the ailments of my patients that were never quite appropriate to talk about on the blog. Somehow, you just knew the right things to say to settle my hysteria and you gave me a laugh when I needed it most.
All my friends from PA Hospital- I know it still seems bizarre that I had the courage to go to Swaziland, but rest assure I'm a lot stronger for it. Dr Mel has "toughened up"! I still have a propensity for tears, but there are some things you just can't change! Your donations and support mean that you're not just my work colleagues- you're also my friends.
To Kristin, Andrew, Susan, Julia and Chris- words will never be enough to describe how much I love you and how much you affected my life. I will never forget the laughter and tears we shared. I tried to share my experiences on my blog, but only you will be able to truly appreciate my experience of a lifetime.
To everyone who read my blog- those I know and those I don't- the blog was more for me rather than anyone else. As I sat and wrote of my experiences, I never felt alone and somehow sharing the heartache, telling people about this forgotten country and describing my adventures helped eased the enormous sadness I felt at times.
To the people of Swaziland- you have changed my life forever. When the rest of the world ignores your tears, I will not forget you. When you feel pain, I will feel it too. Where you have a glimmer of hope, I will encourage you. You are not alone- my thoughts will always be with you.

Reality bites

2009-01-06T03:06:00.000-08:00

Everything is so familiar and yet I still feel somewhat of a stranger in my own home, my own state, my own country.

I knew things would be a little strange to begin with and so far it has been a reasonably smooth transition. I have reliable internet access, I have a phone so that I can be contacted anytime, anywhere and if I need to purchase anything, then it's at my finger tips. I'm back in the modern world and I've taken full advantage of all these modern luxuries.

I had dinner with a colleague last night who is also a friend I love dearly. He's incredibly smart and very experienced. We went through some of my clinical photos. During my time in Swaziland I often took photos of interesting cases or things I had no idea what they were and hoped to look up when I returned. He was able to identify some of the mysterious conditions immediately and I started to develop an uneasiness that can only be cultivated in a mind that is still somewhat traumatised by what she has seen recently. I lay awake all night thinking about what I may have missed whilst I was in Swaziland. Perhaps I could have made more of a difference had I been smarter? Maybe it was incredibly naive of me to go to a third world completely unprepared for what I would see. I am still acutely aware of the feeling I used to have when I would see patients and not have a clue what was wrong with them. It was the worst feeling in the world and despite the fact that I had absolutely no resources to investigate any further, I would still feel like I had "failed" the patient. As my time at GSH passed, I got better at dealing with my feelings of complete inadequacy and I would just resolve myself to the fact that patients would die without me ever knowing what was wrong with them. We had no autopsy facilities. This kind of uncertainty just doesn't happen very often here in Australia and as a young doctor (well maybe not so young, I did turn 31 on Saturday), it was confronting to not be able to have the answers we so desperately go in search of here.

I know in my heart of hearts that I did my very best. I worked my arse off and when I wasn't seeing patients I was often consulting textbooks to try and work things out. I know that my uneasiness is due to my fatigue and my often debilitating self-doubt. I just know that if I decide to work in the third world again, I'm dragging my friend along as my virtual resource centre.....

Today I embarked on my first trip to a shopping centre. Next week I start a new job working in a private emergency department. Surprisingly, the wardrobe I wore in Swaziland- which consisted solely of t-shirts, jeans and cargo pants- won't be appropriate for this new place of employment! I decided that I would take the opportunity to update my wardrobe, redefine my image and become a little more sophisticated. I was somewhat overwhelmed by the experience. I tried on all these clothes and nothing seemed appropriate. I looked like mutton dressed as lamb and realised that no matter what I wear, I can't remove the fact that I'm actually a person who has returned from a third world country and no amount of flash clothing is going to erase the fact that I'm now a different, less sophisticated person. I didn't buy a thing. In fact I didn't even buy any new underwear- which is virtually unheard of because I actually have an obsessive/compulsive tendency to buy extravagant pieces that are riduculously over-priced and inpractical. (However, my sister does design lingerie so I think the problem is genetic)

I ran into an old school friend whom I have not seen in 14 years. She asked me what I had been up to and I simply said that I had just returned from some volunteer work in Africa. She was enthralled and asked questions that simply cannot be answered in a short response in the middle of a shopping mall. She started telling me that she dreamed of doing something like that and that if she won the lottery, she would just spend her life working as a volunteer in the third world. She asked me why would I ever come back to Australia and I replied "Because I wasn't earning a cent and it was destroying my soul watching a population implode upon itself". Perhaps I could have been a bit more subtle. I did not respond positively and I think she was taken back by my blunt response. Basically I said that it was very easy to romanticise the altruism associated with "helping the third world" but in reality it's really tough and not always rewarding. In fact, I think my actual words were "You know, it was a fabulous experience and really challenging but there were also times when it was actually shit and I couldn't wait to get out of the place". She replied with the usual response that is starting to irritate my gut "Well you'll be such a better person because of it". Why does paying witness to utter devastation suddenly make me a better person? I know people are trying to be kind and positive when they say this, but I'd like to think that I was a good person before I even left for Africa. I spend everyday trying to "better" myself. My motivation was simple- I had skills and I wanted to use them where they were needed. I didn't go to "better myself" or because I was "told to go by God", I went with the intention to try and make a difference and the harsh reality is that I made very little difference. Swaziland and it's population are a mess and my very short time there changed nothing. People are still desperately poor and dying tragically from AIDS. This is the reality and perhaps why I cried as I drove myself home. I don't want people to tell me how amazing I am- I'm no different to anyone else who has gone there with the intention to help and every single one of us has returned with the country not being any better off than when we arrived. The problem is so overwhelming, so devastating and so incredibly complex that it's probably why I'm struggling to consolidate the experience and work out just what I need to do next. Perhaps I should just keep my mouth shut and tell people I took a sabbatical for 6 months. No one wants to know what sabbatical is- it sounds too academic.

Goodbye Africa, Hello Australia

2009-01-03T11:05:00.000-08:00

Our last day in Africa was a memorable one- for many different reasons.

We spent the day at the De Wildt Cheetah sancturay which is an internationally recognised sanctuary for breeding the endangered cheetah. We had a great time getting up close with the baby cheetahs and then going on safari to see cheetahs in their natural, albeit, controlled environment. At the end of our day, we were able to touch a cheetah and get a special photo opportunity which will inevitably end up "in the pool room". (sorry to my international readers, but this infamous aussie phrase from the movie "The Castle" aptly describes the significance of this photo).

We then made our way to Johanessburg airport and this is where the chaos began. The computer system was down and it took us over two hours to check in. Our plans to shower prior to boarding the plane were thawted as we literally had to run to the boarding gate. Mum, Rachel and Graeme had seats allocated together, but I was seated alone. This did not upset me much because by this stage, all our nerves were frayed and a few comments between my sister and I were blown out of proportion and I was more than happy to spend the 10 hours in solitary confinement....

First, there was the inevitable problems of seat allocations and double bookings which proved to be our iniial delay. Then there was a problem with getting the passenger manifest to Hong Kong and apparently a vital piece of paper had to be on board the plane before we could legally take off. The searing heat of Johanessburg started to take its toll and there was no air-conditioning. The temperature within the cabin rose dramatically and babies started screaming, pregnant women started to complain and the only resolution to the problem was to open the doors of the plane to allow fresh air in. In total, we spent nearly four hours waiting on the tarmac for this vital piece of paper. Again, instead of complaining along with everyone else- I sat and smiled about how typical this all was for Africa. I had two lovely girls sitting next to me and we laughed and shared our unique stories to pass time.

We at last left Africa and I was doing really well until I open my gift that was given to me from Kristin and Andrew (Peace Corp). You see, it was my 31st birthday and they had been so thoughtful as to give me a present to open whilst I was on the plane. The card they gave me was overwhelmingly kind and sincere and I started the inevitable crying. By this stage, I well and truly had run out of tissues, so Qantas serviettes had to suffice in mopping up the voluminous snott and tears that poured from my face. It didn't help when I listened to the Crowded House CD "Recurring Dreams" which reminded me of my Australian roots. I was a pathetic, lonely mess and I'm sure the sight was enough to frighten young children.

We eventually arrived in Sydney, having missed our connection to Brisbane. We had to wait 4 hours for another flight, but thankfully during this time, I was able to indulge in my first decent coffee in five months and my spirits rose.

We got into Brisbane at about 10pm- 21 hours after we first got on the plane at Jo'Burg. We were met by my delightful cousin Natalie who greeted me warmly with a gorgeous bunch of 12 long stemmed white roses. A beautiful way to celebrate my birthday which had passed without event. Her family had also bought me a spa package for my birthday and I eagerly await the opportunity where I am able to have some of the Swazi dirt scrubbed off my face and the tension eased from my aching muscles.

I didn't get to bed until 1am and it's now 5am and I am sitting here updating my blog. I think it's going to be a long day. I decided to get up as I was lying there ruminating about work which starts in a weeks time. I am starting a new job in a place I have never worked before and I am starting to feel anxious. The truth is, it has been six months since I have practiced modern medicine and I feel a little rusty. At the airport, my family were joking that in a months time, I'm going to be called into the Directors office and he's going to ask me why I've ordered so many HIV tests and why I have sent so many sputum samples to be tested for TB. I'm worried that a patient is going to be wheeled in and the first question I'm going to ask is "What's the CD4 count?" The past five months have immersed me in AIDS, TB and infectious diseases that we only read out here in Australia. My practice of medicine was so vastly different to what is done here and what is expected by my colleagues and the public. This morning I was smiling as I recounted some of the procedures I performed there that I simply would not do here in Australia. I frequently put needles into lumps and bumps that would normally be done under ultrasound guidance here in Australia. I often did procedures where I had to be creative- for instance- we didn't have chest drains, so instead we used urinary catheters to drain massive pleural effusions (collections of fluid around the lungs). I did almost 100 lumbar punctures whilst I was there. My medical colleagues would cringe if they knew the conditions I did this risky procedure under. The patient would lie on their sides. I would not have sterile drapes. My gloves were not sterile. I would have a cotton ball dipped in anti-septic solution which I would use to sterilise the skin. I would not use local anaesthetic. The patients, due to the conditions they lived in, would often be caked in dirt and despite my scrubbing, I would never get that dirt off before I inserted the spinal needle. I would then collect the spinal fluid in a basic blood collecting tube and the procedure, done at the bedside with no privacy curtain and in cramped conditions, would then be left to await the results which often took 1-2 days to receive. Thankfully, I was often able to differentiate the cause of meningitis (ie bacterial or fungal) by simply looking at the spinal fluid and assessing the pressure at which the fluid came out of the needle. With cryptococcal meningitis (fungal), the spinal fluid would be under such pressure that it would come spurting out of the needle and if the fluid was clear, I automatically made the diagnosis and commenced my patients on anti-fungals. I didn't need the laboratory to give me the diagnosis- my accuracy rate was almost 100%. This new diagnositic technique that I developed will be completely useless here. I also had no problem obtaining the spinal fluid. My patients were so thin and cachectic that I didn't need to feel between their spinous processes. I was able to see the correct space and just insert the needle. Australia is one of the fattest nations on earth and I'm now going to have to re-adjust myself to the challenges of performing procedures on obese people again.

I suspect I will have a few sleepless nights ahead of me before I start work in one weeks time. In the meantime, I will spend my days at the hairdressers in an attempt to rectify the disaster which is my hair. I will have my skin scrubbed and my toenails perfected. I'm back to my normal existence and somehow it doesn't seem right to look such a mess. I will keep the blog going for another week or so- this way I can describe the adjustment phase after what has been the challenge of a lifetime for me. I think I will miss the blog and the stories I was able to share with you. Somehow I don't think this will be the last story I tell. It will take a few years, but who knows, maybe my next blog will read "Stories from Sudan" of "Stories from the South Pole"....

2009 in Johannesburg

2009-01-01T12:49:00.000-08:00

I'd like to say that I lived the high life when I celebrated New Years in Johannesburg. Unfortunately, I'm not one for big celebrations and I was in bed by 9.30pm.
We left Cape Town and arrived at Jo'Burg airport to be met by a tour group leader who took us out to a fabulous elephant sanctuary, just outside the city. It was a wonderful experience getting up close to the animals, feeling their leathery skin and muscular trunk. They were so docile and gentle despite being enormous in size. They were rescued elephants who are being rehabilitated and the sanctuary is doing amazing work.
We came back to our hotel and we had high hopes of having a nice dinner to see in the New Year. Unfortunately, the restaurants nearby were all closed and we were left with the prospect of having a very subdued New Years. This did not bother me in the slighest, but it bothered my sister Rachel. There was no way she was going to sit in a hotel room, so she madly searched the internet trying to find somewhere to celebrate. She found a very large casino nearby and decided that we should take our chances by just turning up to see if any of the restaurants had a table. After the previous nights episode of tears, I knew that going to a large place, with large crowds and unpredictable plans was definitely not a good option for me so I told them I was staying behind. I think this upset my Mum somewhat, but I was defiant and they ended up going without me. I had a vegetable soup from room service, read my book and feel asleep long before midnight. I know many of you will think this a rather depressing way to celebrate New Years in a big city, but it was how I wanted to spend my time. I'm not the girl I used to be and it's going to take some time before I can get into the social scene again (was I ever really on the social scene??)
This morning we did a guided tour of Soweto. I have recently finished Nelson Mandela's "A long Walk to Freedom" so my memory was fresh with the stories of apartheid and the ANC etc. I have to admit, I was a little disappointed with the experience. Nelson's house was boarded up as it is being converted into a museum and I couldn't see Desmond Tutu's house as it was behind a large cement wall. The surrounding houses were certainly not flash, but certainly did not display the poverty that was typical of Swaziland.
In the afternoon, Mum, Graeme and Rachel went to a lion park whilst I joined my friend Niel. You may remember that Niel was the paramedic I "worked" with in Bulembu during my volunteer time there. He offered to take me out on an ambulance shift and I jumped at the opportunity to have a first hand experience at treating patients in one of the world's biggest trauma cities.
It certainly was fascinating and I will elaborate more to my emergency medicine colleagues when I get home, but for those of you who are interested, let me just say, it was an eye opener.
For our first call out, we were going to a patient who had been the recipient of "mob justice". This is where the local community decides to take the law into their own hands and issue their own form of punishment. This patient had being stabbed to the head and douced in petrol. We arrived before he was set alight. Getting to the scene was an adventure in itself. At one stage, we were travelling at 180km/hr and I was terrified. I thought I would be returning to Australia in a coffin. Apparently there are other ambulance drivers that travel at speeds of up to 200km/hr and I was grateful that we were taking things "safely". The patient was fine (we had police and fire department as an escort into the community as apparently the people can become violent against the paramedics). He kept commenting that he thought "the white girl was really pretty" (ie. me), but he was soon speechless when Niel told him sternly (in Zulu) that if he made any moves, he'd cut his testicles off. I was touched to be so well looked after....
We were on our way to a second case when I looked at an overpass above the freeway and saw a man hanging over the side. He was attempting suicide and we stopped to see what we could do. As we were running to the scene, Niel asked me "Mel have you ever talked anyone down from a situation like this?". The answer, "Never" and I had no idea what I would say when I got up there. Thankfully, two local men had reached over the side and brought the man up for us. We soon found out that last night, the patient's parents had both been murdered in an armed robbery. They owned a butchery that was randomly targeted last night. After a very long discussion, we handed the man over to mental health services and went on to our next call.
This time it was a major car accident. A combi carry 18 passengers and being driven by a 17 year old unlicensed driver had rolled and there were 18 casualties. I had absolutely no intention of doing an medical work, I was purely there to observe, but when I saw so many casualities, I got involved. I treated the driver who had significant burns and lacerations as well as a closed head injury. I rode in the back of the ambulance to the hospital with him. The ambulance was not equipped at all to deal with paramedics and there was no where for me to sit. We were travelling at ridiculous speeds and being thrown around the cabin. In the meantime, Niel and I were trying to get IV access, using sharps on a patient who may have had HIV. I had blood all over my hands and arms and I have to say, for the first time since I have been in Africa, I started to feel nervous. We made it to the hospital without event and I arrived to what Niel described as the "Baghdad of Johanessburg". It really was madness and I have no idea how the poor people of this country survive any trauma. There was no resuscitation team, in fact, no doctor and the nurse didn't seem too interested at all. Other patients were alongside us, unconscious, unstable and still waiting to see a doctor. My immediate instinct was to just jump in and start treating, but I realised I was unregistered and unable to provide any assistance (legally). It was all so surreal. For a country that appears to be a first world country, it certainly does not offer a first world health service. We also saw other stabbing injuries, but nothing too exciting to write about.
Tonight, Niel, his girlfriend and I join my family for dinner and now we are about to go to bed for my last night in Africa. We are spending tomorrow at a Cheetah park before we fly out in the evening. Can you believe my adventure has ended so quickly? My next entry should be from the comfort of my parents home in Australia.

2008-12-30T12:55:00.000-08:00

Dear "H" (Found in comments section of blog and worked in Swaziland for 3 years)
Thank you so much for your incredibly kind, insightful comments. It means a lot to me that you took the time to leave me a few "words of wisdom".
I don't know you, but you are obviously a humanitarian whose random act of kindness has warmed my heart and also created a few more tears in my eyes.
Thank you

Cape Town continued

2008-12-30T12:22:00.001-08:00

We continue to have a lovely time in Cape Town.
Yesterday we drove down to the Cape of Good Hope. It was incredibly beautiful although I do have to admit that I miss the ever present cows, goats and Swazi people as we drive along the roads. Here in Cape Town, you don't get people waving at you, doing a little dance or screaming "sawabona" to you. This is what I found incredibly endearing about the Swazis- they were always happy to see you and shout out a greeting, even if they didn't know you.
We walked from Cape Point to the Cape of Good Hope. I'm not sure Graeme was too impressed with yet another long, difficult walk. He didn't come with us when we made the steep decline down a cliff face onto the beach and perhaps he was the smarter one because us girls certainly felt the effects afterwards. My large Swazi butt certainly got a work-out coming back up the cliff face! We had lunch at the famous restaurant called "Two Oceans" which stands (apparently) at the junction of the Atlantic and Indian Oceans.
We then drove on to Simonstown where we went goo-gah over the local African penguins that inhabit the place.
Today we went sailing on the harbour and delighted in the seals and penguins that frolicked around our boat. We really have been so lucky with our wildlife sightings on this trip.
It's our last night in Cape Town and we decided to end our time here with a fancy dinner. Graeme chose this beautiful restaurant on the water which specialised in local South African cuisine. I should have guessed that the evening might not turn out so well when I only had jeans to wear to this 5 star restaurant. As I have mentioned previously, I have no other suitable clothing and no money to buy anything new, so my jeans- lined with Siteki mud- had to suffice. The ambience was serene, the decor immaculate and the food and wine list extensive. It was all going reasonably well up until the conversation faltered and I started to let my mind wander. I started crying. I looked at my sisters entree of fried camembert and brie and Graeme's pate of bilton and blue cheese and all of a sudden, I felt desperately out of place. I remembered back to our meals at Good Shepherd Hospital where we would all scramble to contribute something. We would have to be creative and substitute ingredients when we didn't have the variety available. We would drink warm white wine from a cardboard box and we thought it was the elixir of the Gods. We used to congregate at the student house and be so incredibly humble for what we could put together. We would all help prepare the meal together and we would often laugh, cry and share the bizarre stories of our life as it existed. They were some of the most special meals of my life. Sometimes, when we ate, we would talk about what we would rather be eating and through imagination (and the addition of more salt) we were able to "create" amazing feasts. It was all so simple and yet so incredibly delightful. It's only been a few days since I have left and already I miss it terribly. Pre-Swaziland I used to love going out to dinner at fancy restaurants and now it all just seems overwhelming and frivolous. My meals were so much more enjoyable when I was covered in red dust, sweating, laughing until I cried and surrounded by some of the most incredible people I have had the privilege to meet. Despite my best efforts, I continued to cry and Rachel told me to go to the bathroom to "sort myself out" and that just made me cry harder. My parents just sat in uncomfortable silence and I felt incredibly alone because it's going to take a bit more than a trip to the bathroom to sort myself out. Nevertheless, the meal continued without event, even though Graeme returned his ostriech twice to the kitchen because it was undercooked...
From now on, I think we'll be eating at MacDonalds.

Christmas and Cape Town

2008-12-28T12:31:00.000-08:00

Christmas this year was one of the most special that I have had in recent memory. After my ward round, we went to pick up Elsie and her family. (Elsie was the lady who washed my clothes and cleaned my flat during the time I was in Swaziland). Despite the fact that our communication at times was restricted by her lack of english and my lack of SiSwati, we became firm friends and it seemed only natural that I invite her and her family to share Christmas with us. Elsie and her family are really poor. They live in one of the houses made of sticks and mud. Elsie used to take my discarded newspapers as she would use them for toilet paper (and other feminine hygeine products). She would also collect the 5 litre water bottles I used to throw away and she would use this to collect water from a local stream. One of the most special things I have ever done, was pay for one of her daughters to finish school. This was never within my budget, but once I knew that her daughter was not going to finish school because of financial restrictions, I had to step in and I know that I gave her daughter one of the best gifts possible.
Elsie, her husband Sabelo and their 4 children all turned up to Mabuda Farm wearing the biggest smiles I have ever seen. I have never seen chips and soft drink devoured quite so quickly! They enjoyed the turkey and our "umlungu" (white person) salads. We were also joined by Susan and my friend Wiseman (my TB nurse who did a ward round with me once a week and taught me everything I know about the disease). We all had a wonderful time and I will always treasure the memory of the eldest daughter singing her own version of "Silent Night" for us and the two younger girls doing a little Swazi dance as we clapped along. It really was incredibly special. Elsie cried and cried as we said goodbye and I couldn't help but feel somewhat overwhelmed that she was no longer going to be getting a source of income from me. Thankfully, she also works for Susan so there will still be some income for the family.
The next day, I went back to Good Shepherd Hospital to do my final ward round. I couldn't help but feel an incredible sadness as I said goodby to the nurses and looked at my patients for the very last time. Despite the enormous challenges I faced there, the heartache, pain and tears, the reality is, it has been the best experience of my life. I have grown personally and professionally and I feel incredibly privileged to have been a part of that hospital for a short time. I sobbed as I walked up that rugged hill to say my final goodbye to Susan and I then had tears in my eyes as we drove into the airport at the metropolis otherwise known as Manzini. As we boarded the plane, my Mum asked "Are you sure you want to leave?". The answer of course is that I'm not sure I'm doing the right thing by coming home, but I have no money and I have a good job awaiting me when I get home. I also know that there were times when it was all so terribly hard that I struggled to keep well both mentally and physically. I need to go home.

The trip to Cape Town was complicated when our flights and transfer through Immigration were delayed and we missed our connecting flight. Mum and Graeme's nerves were frazzled and Rachel had diarrhoea. It was not pretty. The one thing about my time in Swaziland is that I have developed incredible patience and things like this no longer bother me. This is a virtue that hopefully will remain once I return to Australia as it makes life so much less complicated.

Cape Town is an amazing place. It's a modern, cosmopolitan, harbourside town that is blessed with incredible scenery, good shopping and fabulous restaurants. We are staying at the famous Victoria and Albert Waterfront and compared to Siteki, it feels like we are on another planet.
On our first morning, we went into the retail district. This is when I felt the full effect of the reality I am about to return to. Everyone was just so well dressed, wealthy and happy. There are very few black Africans here and it is hard to believe that South Africa is also a country ravaged by the effects of AIDS. It's certainly not evident here. I was wearing the same clothes that I have worn for the past 5 months- cargo pants, a t-shirt and running shoes. I have been aware of my rather casual appearance during my time in Swaziland, but I was never embarrassed by it- I always looked better than my patients and my nurses thought I was pretty cute in my attire. Here in Cape Town, I was embarrassed and I felt out of place. At one stage, I noticed a big mark on the back of my trousers- some of the pervasive red dirt that coated my skin and my clothes during my time in Siteki. Suddenly, I felt dirty. My hair, which is now troubled with dandruff, was loose and a mass of waves that can only be described as looking like a birds nest. I suddenly wanted to hide away from everyone and I have to say, the enormous crowd of tourists started to bother me. Despite this, I still enjoyed going to the top of Table Mountain. I savoured the meal we had in an Italian restaurant and today I even went on my first ever wine tasting tour in a beautiful vineyard nearby. I felt incredibly peaceful as we walked around the botanical gardens of Kirstenbosch and tomorrow I am looking forward to driving down to the Cape of Good Hope. I also feel incredible privilege at being able to visit these very famous places.
In less than a week, I will be home. Whilst I am looking forward to the familiarity of home, I also admit that I feel some trepidation. I already miss Swaziland and I miss the warmth of its people and the assistance I was able to provide them. I don't think it will be too long before I am back again.

A very Swazi Christmas

2008-12-25T00:02:00.000-08:00

It's Christmas morning here in Swaziland. This morning, I did a ward round with my mum and we got to see all the patients for whom Christmas is a just a remote, far-away concept.
It's been a week of highs and lows coming back to Good Shepherd. Because it's Christmas, I'll talk about all the depressing things first and then I will try to finish on a more happier note.

We got into Mabuda Farm on Sunday night. It was an incredibly long drive from Motswari back to Siteki, but it was a safe, uneventful journey and we all just had tea and toast before we fell into our beds.
The next morning, I got up early to start my ward rounds. I took my mother in with me. Although she does not have a medical background, she feels as though she went through medical school with me and there are times when I think her medical knowledge rivals that of a medical student. She found the ward round to be one of the most fascinating experiences of her life. I have got so used to everything that I often have to take myself back to my very first days at Good Shepherd so that I can empathise with the "shock and awe" that people experience when they first arrive. It wasn't too long before I realised the devastation I had left behind was still pervasive throughout the ward. Most of my patients were languishing in the terminal stages of their HIV. One lady, in her 30s had a massive abdominal tumour that now has formed an enterocutaneous fistula. This is where there is a connection between the bowel and the skin so that faecal material just oozes from her abdominal wall. She was incredibly emaciated and you could see every bone in her fragile body. She was vomiting everywhere and too weak to even roll over to vomit on the floor.
Another patient, this time in her 20s had HIV with a CD4 count of 5. She also had severe TB and was 30 weeks pregnant. She went into labour yesterday (her temperature was above 40 degrees celcius and this often precipitates premature labour). She delivered a tiny little girl who is surprisingly still alive today. The baby isn't exactly thriving and I wonder who will die first- the baby or her mother.
Another lady had this massive fungating tumour on her (R) leg and it had spread to her lungs. I had nothing to offer her and she died yesterday by asphixiation
We have run out of blood here in Swaziland and most of my patients have severe anaemia secondary to the HIV suppressing their bone marrow. The normal value for a haemogloblin is about 11-18g/dL. Most of my patients have a haemoglobin count between 1-4g/dL. They are so pale and weak and can barely walk. To the ones that could walk, I offered to discharge them. I did not see any point keeping them in hospital (where they have to pay for every day as an inpatient and where they are susceptible to catching germs from other patients). I sent them home and told them to return in the next couple of weeks to see if any blood was available. I'm afraid some will be dead in this time.
This morning, Mum and I saw a 21 year old girl with AIDS. She had what is called "wasting syndrome" where she was completly emaciated and not able to move a single limb. Unfortunately, as is regularly the case, she died whilst we were with her. My mother, with her intuitive compassion, just sat and stroked the patients forehead, so at least she had some human contact during her final moments. My mum has obviously not witnessed anyone die before, particularly in such deplorable conditions, but she was incredibly strong and only shed silent tears. I feel that through this experience, she now has a more intimate understanding of what I have seen here. Rachel, my sister who is a lingerie designer, also came on ward rounds with me yesterday and was confronted with desperately ill, AIDS ravaged patients. I think the experience was a little overwhelming for her although she seems to have bounced back today. I think both my mother and sister recognise they are extremely privileged to pay witness to what is happening here in Swaziland.

The highlight of our week here in Siteki has been our time spent with Kristin and Andrew (Peace Corp). On Monday afternoon, My family and I made the arduous trek to their place in the blistering heat. Graeme complained bitterly with every step we took and I think it will be a long time before he lets me forget the exercise I made him endure. However, Kristin and Andrew were thrilled that we made the effort to walk out to see where they live. It also gave us the opportunity to walk through the local villages and see how Swazi's truly live. As usual, the children all ran out to greet us and it reminded me of the photos I have recently seen in the "Australian Woman's Weekly" where Princess Mary was greeting children from Uganda. The experience here in Swaziland is not too different as children here just seem to thrive on us waving at them and greeting them in english. We walked back to Mabuda in much cooler weather and then had Susan over for a lovely dinner. Susan and I spoke of all the local gossip and some of the projects we have been involved in. I became acutely aware that during our conversation my family didn't really have a good understanding of what we were talking about and I realised that even though they are seeing a lot of Siteki during their week here, they will never truly understand what I have seen here in the past 5 months. At times it seems a little lonely when I think of all I have seen and done here.
Kristin and Andrew decided to spend a couple of nights at Mabuda so they could spend extra time with us and I was absolutely thrilled to have them around. After my ward round on Tuesday, the six of us went to the local game reserve called Hlane. It was there we had lunch and got up close to rhino, hippo and elephant as well as antelope and wart hogs. It was Kristin and Andrew's first experience in a game park and they were incredibly excited. It meant a lot to me that we got to share this special time with them. We then spent the next two days together and it was like we were one big family. They got on extremely well with my family and they even commented that it meant a lot to them that they got to be part of a family in the lead up to Christmas. Last night we had a big roast dinner with Susan as well. Much to the horror of my vegetarian mother and sister, we had a big, fresh turkey that had been sacrificed the day before and it was delicious!
It was with many tears that I said goodbye to Kristin and Andrew this morning. They are going to spend two days in Mozambique with some fellow Peace Corp volunteers. We have created such an incredibly special bond during my time here and I love them as though they are my family. Their acceptance of me and all my little quirks, their unconditional love and understanding and their gentle kindness and compassion have sustained me during the difficult times here in Swaziland and I know that they will be my friends for life.
Today we are hosting Christmas lunch at Mabuda Farm. We are hosting Elsie (my housekeeper) and her 5 children as well Susan and various other volunteers around the hospital. It should be fun although I have to admit, after my sad ward round this morning, it will be hard for me to feel overly festive.
I will miss Siteki and the Good Shepherd enormously. For all the heartache and tears that I have shed, I have also been enormously enriched in a way that I have never experienced in Australia. I feel like a part of this place and I suspect I will be returning some day (although it won't be for a while- I need to earn some money. I checked my bank account the other day and I have the grand total of $1 left in it....)
Tomorrow we say goodbye to Swaziland and head for Cape Town. I have already started carrying tissues around with me because I randomly break down into tears- who knows what I'll be like tomorrow..

African adventures

2008-12-20T01:50:00.001-08:00

It has been an absolute privilege staying at Motswari private game reserve in Kruger National Park. It stretches over an unfenced area of the park and therefore allows wildlife to meander around our rondavels, swimming pool and dining areas. At night, we have to be escorted around the site as wildlife, particularly a very curious elephant, can be found on our doorsteps! The accomodation is not just comfortable, but also luxurious and a welcome escape from the oppressive heat. The food is sumptuous and I am sure that in the 3 days that I am here I will put back on the weight I lost during my episode of peptic ulcer.
We are woken each morning at 5am. Whilst this does not appear to be a civilised hour to wake up when one is on holiday, it does give us the opportunity to see wildlife when they are most active. We meet for coffee and a muffin at 5.30am before we start our game drive at 6am. We get back at 9.30am, have a gorgeous brunch before we spend the middle part of the day resting. My family tend to head for the pool whilst I head for the computer and then go and have a much needed rest before we meet again at 3pm for lunch and the commencement of our second game drive. During the middle of our game drive, we stop to drink wine in the middle of the African wilderness and it is such a treat. We get back at about 7.30pm before we go for cocktails and a 5 course dinner. Yes, life has indeed been difficult recently for Dr Mel.
We have seen an abundance of wildlife. We have been up close and personal with elephants, rhino, giraffes, antelope and lion. I used to think that lion were my favourites amongst the big cats, but last night, we had the amazing experience of finding a young leopard and I have now decided that they are most definitely my favourite. My mum has been to Africa 4 times and has never been able to see leopard, so it was such a thrill when we heard that one was wandering around and was quite active. Our guide, Giyani ,heard of the sighting over the radio and made a beeline for the cat. I have to say, it was a hair-raising adventure. I can only liken the experience to being on the "Indiana Jones" ride at Disneyland because at times, we seemed to be airbourne in our open-air jeep. It was simply exhilarating to be going through the african wild with the wind blowing through my hair and the scent of animals wafting past my nose. The white knuckle trek was rewarded by the sight of an exquisite young female leopard who was about 10 months old. She almost appeared to be showing off for us. She perched herself on a log which made for a fabulous photo opportunity and then she sidled up against the jeep just so we could appreciate the intricate patterns on her coat. My Mum started crying as she was so overwhelmed by the experience (is it any wonder why I cry so much when I come from a gene pool like this?)

This morning we saw baby elephants having a wonderful time rolling around in a pool of mud and we were within 2 metres of 7 lions who decided that they were on a photo shoot and gave us perfect poses.

I feel like the luckiest girl in the world having such a magnificent experience.
Tomorrow, we face a very long drive back to Siteki. Whilst many of you may think I'm crazy, I have decided to work at the Good Shepherd whilst we are there for 4 days. The fact is, I miss the patients. I miss being with Swazi people. Their smiles, their kindness and their lives have affected me deeply and I just want another opportunity to be with them- even if it means facing the devastating consequences of HIV. Whilst I describe the many wonders of Kruger, I also spend a great deal of my time by myself thinking about the past 5 months at the Good Shepherd. Whilst my family will tell you that I haven't changed a bit, the fact is that this experience has changed me forever- we are on holidays at the moment and the full impact of my experience in Africa is not being felt. There are times here when I actually struggle to enjoy myself because I am still trying to recover from paying witness to abject poverty. I'm still thinking about the diseases that have ravaged my patients and I am still battling with doubts about whether I should be coming home to my life of privelege or whether I should continue to be where I am most needed and most appreciated. Life here in Africa has been the greatest challenge of my life so far but I still feel as though my time here is not over. I am struggling to identify just what I should be doing with my life.
Nevertheless, I will continue to try and enjoy my time here. It's truly spectacular and if any of you have ever considered an African safari, I can assure you, it's what dreams are made of.

All of us to Bulembu

2008-12-19T01:40:00.000-08:00

Mum, Graeme and Rachel were incredibly excited about visiting Bulembu and we made our way there on Tuesday.
The weather was simply terrible. It was raining and the mountains were shrouded in mist. Visiblity was perhaps four metres at best. This only compounded the treacherous conditions as we made our way up the mountain which is a dirt (mud) road with many twists and turns. Rachel was designated driver and she took the corners like a natural rally car driver. The car was coated in a thick crust of mud when we eventually made it to our destination.
Our first stop was the Sullivan's where we caught up with my "famous five". The kids just loved making new friends and we spent hours playing with them. I think Rachel and I now have additional pressure to produce grandchildren as Mum and Graeme were in their element with this group of 3-4 year olds.
The next morning, we went over to the other orphanage which houses the babies. Again, my family were just overwhelmed playing, cuddling and making silly baby sounds which may as well have been SiSwati! My Mum got particularly attached to Simon. He arrived at the orphanage only a couple of weeks ago and his story, like everyone else's, is incredibly sad. He's two and a half and both of his parents died of HIV. Unfortunately, he too has AIDS. For the past year or so, he has been living with only his 9 year old sister. She has AIDS as well. Somehow, she has been feeding him and providing him with water. Someone in a nearby village noticed that it was just the two of them living alone and they notified the authorities. Now both of them are at Bulembu. Simon has just started ARVs and has a respiratory tract infection so he was feeling quite poorly. He's also an incredibly sad child and has obviously been quite disturbed in his short life. Mum spent a lot of time just holding him and trying to comfort him. When we left, she started crying and it was quite distressing for me to watch as I knew exactly what she was feeling.
I also felt a tremendous sadness as I left Bulembu. I have so many special memories from that place and I will treasure every second I spent with those children. I can't believe that I may never see them again. Heather and Andy (who care for the 3-4 year olds) have promised that they will send me regular updates and photos of the kids and I hope that this is enough for me to feel like I am still part of their lives.
We donated a suitcase full of children's clothes that my friend Karin had kindly organised and we also donated over $5000 (AUS) that many of you kindly contributed. Thank you so much- you have certainly improved the lives of many Swazi babies.
We then made our way to Kruger National Park in South Africa. Only a week ago when I was transferring that kid with the scaphoid fracture, I noticed a chimpanzee sanctuary that was established by Jane Goodall. Upon arrival to Swaziland, I immediately informed my family that we needed to adjust our itinerary slightly so that we could include a visit to this place. Whilst I love people, I also have a passion for primates. I have been fortunate enough to travel to Rwanda to see the gorillas and Borneo to see the orangutans. Chimpanzees, although not exactly in the wild, was an absolute "must see" for me.
The sanctuary is home to chimps that have been rescued from places such as Sudan, Angola and Mozambique. It's incredibly tragic to hear of some of their stories. Some have been held in nightclubs throughout Africa as "attractions" where people have been able to give them alcohol, cigarettes and even illicit drugs at times. Often they have been held in tiny cages with little access to food and water. Some were kept by people and used as "surrogate children" and dressed up in human clothes and fed a diet of pizza, soda and chips. All incredible forms of cruelty. Others were kept by people who regularly beat the animals and one of the chimps has even sustained brain damage and has the intellect of a chimp much younger. All of these chimps have been brought to the sanctuary where they are enclosed in hectares of protected forest. They are rehabilitated so that they can live as they would in their natural environment. They will never actually be able to return to their natural environment as they will be an immediate target for poachers. Chimpanzees are on the verge of extinction and as humanity, we should be disgusted with ourselves. The experience I had there was enlightening and uplifting and certainly one of the highlights of my trip so far.
We are now at Kruger National Park and staying at an incredible place called Motswari Private Game Reserve. It's an amazing place and deserves a individual blog entry which will follow in the next few days.

Melanie's family at last in Swaziland

2008-12-15T07:41:00.000-08:00

At last my family have arrived!
They arrived on time, much to my relief and I started crying as soon as I saw them. Unfortunately, I was able to see them waiting in customs, so by the time they had cleared customs and come through the luggage area, I had been crying for quite a long time! My Mum just held me for the longest time and I sure it made for dramatic entertainment for all the on-lookers.
In typical Swazi style, there were a few hiccups- namely, their luggage didn't arrive and then the transfer we had organised to take us back to the hotel also didn't turn up.
I have to admit, whilst I didn't want to see my family frustrated, I was inwardly smiling at just how typical this was for their arrival here in Swaziland. If everything had gone perfectly, then it would have made a mockery of all I have experienced in Swaziland so far!
Thanks to me now being considered a "local", I was quickly able to organise transport for us and we made our way to the hotel- sans luggage. Thankfully, Mum, Rachel and I share a similar body habitus (although I have been reminded that my butt size exceeds theirs by vast quantities....) so I was able to lend them some clothes. Graeme's a man so it didn't bother him at all that he didn't have another set of clothes.
3 out of their 4 suitcases arrived this afternoon, so they all now have their clothes and the vast quantities of children's clothes, colouring in books, pencils, balloons and 1500 condoms that will be distributed throughout the Swazi community. Rachel carried the condoms in her hand luggage and apparently the guys in the luggage scanner looked at her very strangely as she went through...
Today we went to Swazi Candles for lunch and we did the few "touristy" things that we are able to do in this area.
Tomorrow, we leave for Bulembu and no doubt this will provide for a very interesting blog post. Stay tuned.

Combis and Chaos

2008-12-13T01:06:00.000-08:00

My last couple of days in Bulembu were without any medical problems except for some minor abdominal pain and gastro in some of the Swazi 1000 participants
I spent Thursday afternoon with my friend's- the Sullivans. I was supposed to borrow their computer so that I could type out protocols for the Clinic, but I got distracted by a much more entertaining project. They were responsible for decorating brown paper gift bags that were going to hold gifts for 65 of the older children in the orphanage. As my family will testify, I am an "ideas person". I come up with what I consider "fabulous" ideas, but often they involve a lot more work than if we just simply went with the original task at hand. I convinced the Sullivans that we were more than capable (as a team) at hand painting stars on all the bags. My "idea" was met with some hesitance, but I eventually convinced them that it was not a difficult task and the extra work would be worthwhile. I'm surprised they didn't just get a gun and shoot me.. It took hours and a lot of effort and mess to paint those damn stars, but if I do say so myself (and the Sullivan's eventually agreed), the bags turned out beautifully and those older orphans are going to wake up on Christmas Day to some very brightly coloured, lovingly made, gift bags!

In the evening, I was sitting watching "Hi-5" with the kids. I had Lily on one knee and Doris on the other. I'm not sure how much communication goes on between 3 year olds, but obviously word had got out about the mysterious soft foam under Aunty Melanie's shirt. Lily, being the braver of the two, suddenly pulled down my t-shirt and pointed at my bra asking "What's this?". Pretending that I was quite accustomed to having my breasts exposed, I proceeded to tell her that it was something you wore when you became a lady. (I have no idea where the crap that comes out of my mouth comes from). They fingered the lace and ribbon and seemed quite content with my answer. I congratulated myself on being able to make sense of the world for two 3 year old African orphans.

It's not easy getting to and from Bulembu and I was faced with the challenge of somehow making my way back to Manzini. After a morning of contemplation, I decided that my only option was public transport. Thankfully, my friend Lorraine (Social worker from Zimbabwe) was also trying to make her way to Mbabane, so we decided to travel together. The initial trip from Piggs Peak to Mbabane was quite pleasant. I insisted that we catch a big bus as I considered this the much safer option compared to the mini-buses described as "combis" here in Swaziland. The journey was pleasant and Lorraine and I talked the whole way. She was going to catch another bus from Mbabane, to Jo'Burg and then catch another bus to Zimbabwe and she had a big trip ahead of her.
When we reached Mbabane, I knew that the rest of the trip was not going to be as pleasant. No big buses are available.The bus rank contained at least 100 combis and all of them were blasting their horns trying to attract people onto their buses. People were scattered everywhere all intent on serving their own purposes. Rubbish littered the ground because here in Swaziland, it not deemed socially inappropriate to simply throw your rubbish on the ground. People were yelling and bustling around and I tried my best to pass through them with my two pieces of luggage. I eventually found the combi that would take me to Manzini. I sat down and waited for the combi to fill with passengers (there are no scheduled departure times for combis- you just have to wait until they are full before you can leave. Sometimes this can take half an hour, sometimes it can take 6 hours...) I knew I was in trouble when there was no where to store my luggage. I thought that perhaps I could pay for an extra seat and have the luggage next to me. This is not the "Swazi way" and this "fabulous idea" of mine was prohibited. Now when I say that the combi cannot leave until it is full, I mean FULL. If there is a seat for two, then it must seat at least 3 passengers, sometimes 4. I sat there as more and more passengers were being packed in like sardines. I started to verbalise my concerns about my luggage and in typical Swazi style, my concerns were brushed aside. I'm white and I'm female. I don't know shit.
Eventually, the combi was full and as I predicted, my luggage didn't fit it. People were starting to get pissed that the "white girls'" luggage was causing a problem and I was decidedly uncomfortable and yet unable to provide any solutions. Eventually, this kind Swazi man offered to hold my massive suitcase on his lap, much to my horror. I couldn't hold the suitcase as I was in a seat for two being occupied by four people. I only had one butt cheek on the seat and I couldn't balance the bag. Once we managed to close the door, we started off at speeds well above the legal limit. On combis, there is always a man who stands on the step of the combi to help maintain calm and collect the money. This guy thought nothing of leaning over me so that he could chat with his mates up front. His body was pressed up against my face and I could barely breathe. This, combined with the body odour that eminates from the sweat of others crammed up against you, makes for a very unpleasant journey. I knew I had already caused "trouble" so I didn't dare complain about his body encroaching on my personal space.
After what seemed like an eternity, we finally reached Manzini and I was suddenly able to breathe again. I then had to struggle trying to get my luggage off the combi and drag it through the bus rank (again crowded with combis, Africans and rubbish) to try and find myself a taxi to take me to my hotel. I eventaully found a "taxi" which in fact was a car that was older than me- lacked windows and a door that couldn't be opened from the inside. I seriously doubted it's ability to make it out of the bus rank, let alone get me to my destination. But, this is Africa and things continue to surprise me. I made it safely to the hotel and I was greeted by kind, Swazi (yet english speaking) staff who seemed to appreciate the fact that I was a little frazzled after my rough journey. They escorted me to my room where I proceeded to collapse on the bed. However, the bed was soft, the pillows in abundance and the room was cool thanks to air-conditioning (something I have not experienced for 5 months). After a quick meal, I settled my self into the bed, snuggled under the covers and proceeded to watch two movies. One was a Julia Roberts movie called "Dying Young" which made me cry like a baby, but this was soon followed by "Miss Congeniality" and I found myself laughing out loud. For a while there, I actually forgot that I was in Africa and I felt safe and comfortable.
Only one more sleep until I am joined by my family and I am incredibly excited. I keep hoping that their flight is uneventful and goes according to schedule. Not surprisingly, I am a little cynical and trying to prepare myself for the inevitable delays that may occur. I'm going to try to be patient and understanding, but I have no doubt that once they finally arrive, I'll probably dissolve into tears.

Bulembu, Barberton and Breasts

2008-12-10T22:37:00.000-08:00

I visited South Africa prematurely today. Not for pleasure but rather to take a 16 year old boy with a hand injury. He fell on his right hand whilst playing soccer last night. He was in a lot of pain and I suspected a fracture, so I applied a backslab and planned to take him to South Africa the next morning for x-rays. (We could have gone to a hospital in Swaziland but we knew we would have had to wait for at least 8 hours and if there was any pathology there are no orthopaedic surgeons to treat it).
We left for a place called Barberton which is about an hour away from Bulembu. The scenery was gorgeous and we were able to listen to an SA radio station which played music very similar to what I listen to in Australia. I think I have mentioned this previously, but I have really missed music whilst being here in Swaziland and any song that I recognize provides me with immense pleasure. I even sung along with John Farhnam (an Aussie icon) as we listened to “You’re the Voice”.
Anyway, back to the patient. We had x-rays done in Barberton and they were normal. I was still highly suspicious of a fracture of a bone called the scaphoid and the patient had developed numbness of his entire thumb which I was concerned about. I managed to get my hands on a list of orthopaedic surgeons in a nearby town called Nelspruit. I simply called one randomly, explained that I was an Aussie doctor working in rural Swaziland and asked him if he would mind providing me with a second opinion. I think he thought it was quite a novelty to have a random Aussie doctor call him and he agreed to see us whenever we arrived. Let me tell you, I got my first inclination of the culture shock that awaits me when I get home. Nelspruit could well be any suburb that I have visited in Australia. The houses were very similar, there were shopping malls and the medical facilities were even better than most private practices I have seen in Australia. It was all quite bizarre to be in Africa and yet feel like I was back home. The only difference I noticed was that all the houses had large concrete fences surrounding them and on top of these were barbed wire. Apparently this level of security is quite benign compared to what I will experience in Johannesburg.
We saw the orthopod and his office was immaculate with modern furnishings and expensive pieces of art work. Again, it crossed my mind that as an emergency physician I will never be able to have the beautiful office with plush waiting room and there is part of me that thinks I’m absolutely crazy choosing the specialty that I have…
Anyway, the orthopod agreed that it was likely to be a scaphoid fracture (these fractures often don’t appear on x-ray until about 10 days after the injury). We were instructed to then go somewhere else to go and get the plaster. We got to that place and were told that the patients medical insurance didn’t cover the plaster and that we had to go and get clearance for it at some other place. We couldn’t find this other place and by this stage I was getting concerned that we would not make the border gate that closed at 4pm. I certainly didn’t want to have to find a place to stay overnight. I made the decision that I was perfectly capable of applying a scaphoid plaster and we decided to come back to Bulembu and apply the plaster here. It’s funny, but I have become a little insecure in my abilities here. I was so incredibly challenged with my patients at Good Shepherd that I’ve started to forget that I actually can practice my “western skills” here as well. I guess what has also concerned me is that at Good Shepherd we did the absolute best we could with what little resources we had and this often fell short of what is considered “Western standards”. I got used to that and began to accept it. Now, I am treating wealthy, white South Africans and the standards and expectations have changed dramatically. I’m now going to great lengths to treat relatively benign complaints when for the past 5 months I have been desperately trying to treat incredibly serious, life-threatening conditions that I could do little about. The irony is, I think I got a lot more from the effort I made there (despite the results being tragically poor) compared to the efforts I am making here (with very successful results).
The border crossing was interesting. The South African side was all computerized and I was scrutinized more closely. The Swazi side consisted of hand writing my name in a big book and then being asked if I would like to purchase some craft work from some ladies loitering in the office. It was particularly endearing and I know that I will miss the old-fashioned, traditional ways here in Swaziland.
I applied a particularly good scaphoid plaster back in Bulembu and the patient walked away without even thanking me for the efforts I had gone to throughout the day…..

I was then able to go and spend the late afternoon with my special friends. We had a wonderful time as we watched a movie called “Madagascar”- a children’s film that I have not seen previously. The movie was hilarious and it was particularly special because I was never without a child in my lap. The orphans are in no way institutionalized, but they do seem to have a more pronounced concept of “sharing”. Without any discussion, they would each spend about 20 minutes curled up in my lap and then they would leave so that the next one would get special “cuddle time” with Aunty Mel. I treasured every moment. I made sure I gave each of them the same number of kisses and made sure I told them each that I loved them as they left my lap. I have bonded incredibly well with these children and I know I am in for one big heartache when I leave. There are about 50 orphans under the age of 4 and I spend nearly all my time with the 3-4 year olds. I thought I would just take a moment to describe each of them and hopefully when I can download photos, Courtney will be able to attach them to my blog.

Enoch is 3 and has been at Bulembu since he was born. He has the most incredible smile and he definitely knows how to use it! He “flirts” with me and he knows that this often gains him an extra cuddle and kiss compared to the others. Enoch is particularly talented with his ball skills and I know that if he is given the right opportunities, he could become an amazing sportsman when he grows up.

Dexter is almost 4. When I first met Dexter he was barely able to walk. He was incredibly sad and never smiled. In the time that I have known him, he has flourished. He is almost able to run and whilst his vocabulary is delayed compared to the others, he has progressed in leaps and bounds. He now has this drop-dead gorgeous smile and has become particularly affectionate towards me. I scoop him up and start kissing his ears whilst telling him “I’m going to eat your ears” which makes him giggle uncontrollably. He has now taken to coming up to me and saying “Aunty Mel, can you eat my ears?”

Alan is the oldest of the 5 and he will advance to the next level in the orphanage next year. He and I are not so close but he always informs me of any recent “news” like if he has had a fall, has a headache or has a sore ear. Kisses cure everything.

Lily is gorgeous and from the moment I met her I started telling her so. She now runs up to me every time she sees me and says “Aunty Mel- I’m gorgeous!” She has recently got glasses and a whole new world has opened up to her. She’s definitely a “girlie girl” and she loves showing me the contents of her handbag.

Doris is the youngest and the most recent addition to the group. She is incredibly affectionate and loves a cuddle with her Aunty Mel. During our cuddle times, she has discovered that I wear padded bras and she is completely fascinated by them. She’s often poking me and marveling at the fact that I appear to have foam permanently attached to my chest. I don’t have the heart to tell a little African girl that it’s probably not socially appropriate to be fascinated by my breasts.

Another day over and now only 4 sleeps until the family arrive.

Friends at Bulembu

2008-12-09T06:00:00.001-08:00

Less than one week to go before Mum, Graeme and Rachel arrive in Swaziland. I am counting down the days, hours and minutes. I miss them so much. I am going to have to try and remember the feeling of missing them, because I will need to draw on the experience the next time they drive me absolutely nuts……
Their bags are packed and they have informed me that amongst a huge amount of donated items they are bringing with them, they also are bringing 1500 donated condoms. I have to admit, I wasn’t overly thrilled when I heard this. Whilst I am certainly not against condoms, I just am fearful that if word gets out in Siteki about the donation, I will forever be known as the “condom doctor” and this is certainly not the legacy I intended to leave behind.

Last weekend, I was incredibly blessed to have my other “family” here with me at Bulembu. Kristin and Andrew made the treacherous trip here and they arrived on Saturday morning. It was wonderful spending time with them and showing them all that I have discovered here at Bulembu. We enjoyed ourselves playing with the orphans, eating good food and sleeping in plush surrounds. Kristin called upon my skills as a doctor when she randomly fainted, but I think that good coffee and red wine were a shock to her system. She recovered without complication. They had to return home to Siteki on Sunday afternoon, but it wasn’t our last goodbye- I will be catching up with them again over Christmas when my family and I are in Siteki. I feel like the luckiest person in the world having them in my life. I love them dearly and consider them part of my extended family. They have certainly embraced me with tremendous kindness and comfort and I know that our friendship is going to span a lifetime. When they left, I was filled with an overwhelming sadness. Whilst I battle with my guilt about leaving Swaziland, I also battle with my desire to remain here with them so that we can see this adventure through together. I suspect I will spend the next two years worrying about their safety and comfort.

I have made other friends whilst staying in Bulembu. One of my good friends, whom I have dinner with every night, is Lorraine. She is a social worker and has recently left Zimbabwe to take up a position here in Bulembu. We have spent countless hours talking about the conditions she has left in Zimbabwe. Her husband came to Swaziland first and she soon followed him. Trouble is, they were so uncertain about the conditions in Swaziland, that they left their 18 month old son in Zimbabwe with her parents until they found stability here in Swaziland. Now that they are both employed, they are trying to get their son a passport so that he can join them. The regime in Zimbabwe is so bad that obtaining a passport may be quite difficult (and will probably require a lot of money to bribe officials). I cannot imagine what it would be like to live with this kind of uncertainty. They had to leave Zimbabwe to escape a brutal regime and now they have to anguish about getting their son to join them. (not to mention the concern associated with the current outbreak of cholera)
Before getting her job in Bulembu, Lorraine has worked in other orphanages throughout Africa and she has described absolutely horrendous conditions and appalling abuse of children. She has also told me of some of the terrible abuse that children have had to endure prior to reaching the orphanage and some of the stories have made me physically sick. There may well be an international charter that tries to protect the rights of children, but it is certainly not enacted in some parts of Swaziland. Thankfully, things here at Bulembu are a refreshing change for her and I know she will do well. Her role will be to provide counselling for some of the older orphans and hopefully she will help co-ordinate some international adoptions. Whilst I am particularly involved with the orphanage that looks after babies and toddlers, there are other orphanages here that house older orphans. One of the places here called “Jacaranda” exclusively cares for girls that have been abused (in all forms) and I suspect she will have a role in their rehabilitation as well. Lorraine is an extraordinary woman working with extraordinary people, so there is great potential for her here at Bulembu.

I have also had the pleasure of catching up with a man called Volker, whom I met at the Board meeting when I last came to Bulembu. Yet again, another extraordinary person. To simplify his role here, I can only describe him as another “Bill Gates” but on a smaller scale. He was an entrepreneur in Canada when he decided to focus his efforts on establishing Bulembu. He is a very clever business man who has been very successful but has now devoted his time, knowledge and resources to establishing and maintaining this novel place. The first time I met him, I was incredibly intimidated by him. I thought my role in Swaziland paled in comparison to his work here (and I still feel the same way) but I am no longer intimidated and we have become friends. He teases me incessantly and laughs a lot at my expense, but he is sensitive to what I have seen here in Swaziland and the other night, after Kristin and Andrew left, he paid witness to one of my unfortunate “meltdowns”. He could tell that I was a bit down, so he asked me to join him outside for a chat. He smoked and drank red wine whilst I cried and cried about the nightmares I am still having about my time here in Swaziland. I spoke of my enormous guilt and the sense that I am “abandoning” the disaster here. Perhaps it’s his wisdom and experience that he has accumulated over the years, but he was able to talk to me in a way that made sense and gave me tremendous comfort. I appreciated his down-to-earth response and the fact that he doesn’t see what we are doing here through “rose coloured glasses”. I haven’t made an enormous difference here, but the reality is that no-one, despite their best abilities and intentions can make a huge difference here. It’s all about doing our little bit for the time that we are able to do so. I am currently reading a book at the moment called “The problem with Africa” and whilst it talks about international aide on a much grander scale, it also highlights that there are problems here that will perhaps never get better. Quite a sombre concept but helps put my experience here into perspective. I appreciated his paternal overtures and the wisdom he kindly afforded me.

Heather and Andy Sullivan and their daughter Cassi also provide me with a “home away from home”. I spend most afternoons with them and their small group of orphans. They also allow me to use their computer to type out my blog in a word document- something I am particularly grateful for. They are looking forward to meeting my family next week.

My “official work” continues, although no way near as dramatic as what I have experienced at Good Shepherd. Lots of ankle sprains, lacerations and bouts of gastro that leave me terribly disinterested, however, I did evacuate a girl yesterday with appendicitis and I hear she is doing well after surgery in South Africa.

Today, Neil and I spent the morning teaching the nurses here how to treat acute emergencies. I spend the afternoons typing up protocols for emergencies as well as simple “clinic” presentations that I got particularly good at dealing with during my time at Good Shepherd.

I spoke to my Dad this morning and he asked me how I felt about Christmas that is just around the corner. The truth is, it doesn’t feel like a typical Christmas here and I suspect many in Swaziland who are particularly afflicted with poverty won’t even know it’s Christmas. It certainly will be a different Christmas experience for me, but at least I will be with my family. 5 days to go…..

Internet site for Swazi 1000

2008-12-04T23:55:00.000-08:00

If any of you are interested in following the progress of what is going on here in Bulembu, go to the following site:
www.mote.co.za
Follow the links to "Swazi 1000"

Bulembu continued....

2008-12-04T23:53:00.000-08:00

I’ve now been in Bulembu for almost a week and I have achieved much more than I thought I would. Neil and I finally sorted out all the donated goods and now we have set up an Emergency Department here at the Clinic. I am so proud of what we have achieved. It looks great and is incredibly functional. Next week will be spent making up Emergency protocols suitable for the nursing staff to enact and then we will spend time teaching the nurses how to deal with simple emergency situations. I really feel like I am “giving back” a little of the knowledge I have accumulated over the past 6 years as a doctor. Perhaps I will take sometime out in the years to come just going to third world countries and establishing basic emergency services. Who knows what the future holds for me?

The medical “emergencies” that we have been seeing in the volunteers have been trivial and not dramatic. The patient we transferred to South Africa is still in hospital and has been diagnosed with a heart condition, so I am reassured that our dramatic evacuation was entirely appropriate.

Word has got out amongst the locals that there is a doctor in town and I have had various requests to consult with patients. Yesterday morning I went to the local kindergarten and looked in kids ears and down their throats and felt their little rounded bellies that are there because of protein malnutrition. My “consulting room” was outside on a picnic table and it was certainly a different way of practicing medicine. I don’t think I did much other than reassure and give some dietary advice. I have also seen a workman who got dirt and grass in his eye and various other minor complaints. I went and saw a young woman who appeared to be having a psychotic episode. Her work colleagues had tied her hands and feet together to restrain her, but after I arrived and realised that there could be some cultural component as well as a minor psychiatric component, I was able to untie her, give her some valium and take her home. Everyone keeps asking me why I don’t stay in Bulembu permanently, but the honest truth is that there is not enough here to keep me stimulated and all my skills that I have gained as a doctor would not be put to good use.

Now that I have been introduced to yet another Swazi community, I face the same barrage of questions that I have had to answer numerous times already during my stay in Swaziland. Firstly, everyone wants to know if I’m married. Here, you need to be placed in a “box” that society assigns to you, and here in Swaziland, I do not fit into a “box”. They all have a very difficult time understanding how I can be a “successful” doctor and yet at the same time be a “failure” by not being married. The perpetual, yet unanswerable question is “Why are you not married?” I tell them that Aussie men just don’t think I’m pretty enough (it’s a simple enough answer and quickly deflects from the all-important M-word!) but they scoff and tell me that Aussie men are obviously stupid (and I quietly agree) because here in Swaziland, they consider me quite gorgeous.

Despite being away from Good Shepherd, I still find myself a little “fragile”. Sleep has been my constant problem since arriving in Swaziland. If you remember back to many blogs ago, I mentioned that I was initially having nightmares. I no longer have nightmares but I am often plagued with debilitating insomnia. I have always been a bit of a “thinker”, but now I’ve become a ruminator and I lie in bed at night just thinking very deeply about what I have seen and encountered during the day. Sometimes I lie awake at night and wonder what I am returning to once I get back to Australia. I have to admit that the insomnia got so bad at one stage that I started taking diazepam (“valium”) but I didn’t like the hangover effect that it left me with the next day. I then started to take a drug called “Mersyndol” (it’s extremely cheap here) which contains codeine and a sedating anti-histamine. I found it worked really well and left me feeling refreshed the next morning. Trouble is, the insomnia got worse and I’ve became dependent on the Mersyndol in order to get to sleep each night. I’ve never had this problem before, but then again, I’ve never worked in Africa before. Needless to say, I’ve recognised that I need to stop the drug and I decided that I would use my time here at Bulembu to “detox”. I’ve found it to be incredibly unpleasant. I still lie awake at night for countless hours and I just can’t seem to turn my brain off. I have been averaging about 4 hours of sleep at night and this is about half of what I need. However, I’m determined that I need to establish a normal sleep pattern and I have to do it now, otherwise it’s just going to get worse.

I visit my special group of friends (ie the orphans) on most afternoons. We have established a regular routine where I watch “Hi-5” with them and then we colour-in and draw until they have their bath and dinner. I am privileged to be the recipient of lots of cuddles and kisses and I find it very relaxing just to colour and “be in the moment” with these young children.

Kristin and Andrew (Peace Corp) are coming to spend the weekend with me and I am very excited by the prospect of seeing them. I am still in regular contact with Chris and Susan. I miss seeing them everyday. Susan leaves tomorrow for a 2 week holiday in Sri Lanka with her husband and Chris returns to the States next week. That will just leave the Peace Corp as the only original members of our gang left in Swaziland. I am in regular contact with Julia and she seems to be settling back into western life adequately.

I still seem to have a daily battle with my own conscience about leaving Swaziland. There is so much to be done here and there is a desperate need for people like me to come in and try and make a difference. I feel incredibly guilty that I am returning home to all my luxury and privilege when I know I am abandoning a place that is in the face of a human disaster. I don’t know how to reconcile my feelings about wanting to help but also wanting to return to the life I knew previously. I suspect it is going to take me some time to work through all of these emotions.
My parents have contacted me and I have been delighted to hear that those who read my blog have donated nearly $3000 (AUS). Never in my wildest dreams did I think we would raise so much and I am incredibly appreciative of your extraordinary generosity. It is just a little over a week until my family arrive and I can assure you, the benefits of your kind donations will be felt immediately as soon as my parents deliver the cash. THANK YOU. You have benefited the lives of ~45 orphans and I will ensure that you see for yourselves the incredible difference you have made.

Swazi 1000

2008-12-01T23:05:00.000-08:00

I got to bed late on the night of Thanksgiving and this combined with having to pack up my apartment, simply exhausted me, even before I got out of bed.
I was determined to make sure that all my patients on the ward were thoroughly sorted before I left and the ward round was long and complicated. By the end of the round, my nerves were frazzled and I was stressed out. I was drenched in sweat as the weather was unbearably hot and I was feeling the beginnings of a migraine coming along.
Thankfully, at midday, I was greeted by the delightful Heather and Andy Sullivan. They are the couple from Bulembu who care for the orphans aged 3-4 years of age. I have become quite close to them during my time in Swaziland and I was incredibly touched when they offered to make the 6 hour round trip to pick me up from GSH and take me back to Bulembu. The trip back to Bulembu was long, stifling hot and difficult as we made the treacherous climb up the mountain along an uneven dirt road. By the time we reached Bulembu, I knew I was in trouble. Ever since I can remember, I have suffered debilitating migraines that tend to manifest themselves at the most inopportune times. This was one of those times and unfortunately, I never made it to the “carols by candlelight” I was looking forward to because I was hurling my guts out whilst thinking that my head was going to explode. It was not pretty and it’s during times like this that I feel the most lonely.
I woke the next morning and felt much better. I looked around me and knew exactly why I felt better. I am being accommodated at the Lodge and my bedroom is simply delightful. Beautiful double wooden bed- with at least 100 thread count sheets. The polished wooden floors, the bath with claw feet and the features that take you back to a bygone era all make the experience incredibly comfortable and welcoming. The fact that I am being provided with three gorgeous meals a day and the staff know me well all contributes to me feeling like I have reached paradise. I am being treated like a first rate Swazi princess and I couldn’t be happier.
In case some of you have forgotten, I am here for “Swazi 1000”. This is a two week project in Bulembu where college students from South Africa have congregated to volunteer their time to restore buildings that will house orphans. I am incredibly privileged to be a part of this event as it is simply spectacular. The sheer enormity of this undertaking, the remarkably special people involved and the work that is being done- is overwhelming. This project is being co-ordinated with military precision and I am in awe of what is being accomplished.
I am here as the doctor who is available to deal with anything medical- emergency or otherwise that comes up during the two week exercise. I am accompanied by a young man named Neil. He is currently a student at Johannesburg University studying a degree in “emergency medicine”. Whilst this is not a medical degree, his knowledge is excellent and equivalent to what we term “Advanced care Paramedics” in Australia. He and I work really well together and already, only 3 days into the event, we have cared for numerous patients. Mostly lacerations, but some abdominal pain and cases of tonsillitis etc. We are amazingly equipped. Neil has brought defibrillators, intubation equipment, enough drugs and equipment that we should be able to cope with almost any emergency. I have more resources available to me than what I had at Good Shepherd Hospital!
Thankfully, these resources have already proved invaluable to us. Yesterday at 1pm I was called by Neil who told me that he had a 20 year old patient with chest pain and shortness of breath. I have to admit, I didn’t rush to this case. The night before I had some students come to my room and tell me that a young girl was seriously ill and it was an emergency- I jumped out of the bath, threw some clothes on and ran over to our temporary “hospital” only to find a young girl with some intestinal cramping. I took the opportunity to define what should be considered an “emergency”. When I was called to a 20 year old with chest pain, I didn’t think there was much to rush for. When I got there, my opinion changed immediately. The patient looked dreadful- the pulse was racing, the patient had laboured breathing and was drenched with sweat and in severe pain. The patient also weighed about 150kg (~300lbs) and suddenly I knew that I had to consider that this young patient may have a cardiac condition. Thanks to the amazing equipment Neil brought along, we were able to get a 3 lead ECG and I didn’t like what I saw. He was having dynamic changes to his ST segments and I started to worry that although unlikely, this patient maybe having cardiac ischaemia. My emergency training has provided me with many skills and diagnostic abilities, but I have to admit, over the years, I have developed this “gut instinct” that tells me when something is going wrong. I made the decision that we couldn’t keep the patient here in Bulembu and that we needed him evacuated to South Africa. The people here were simply AMAZING and thanks to Neil’s knowledge of the South African medical system and modes of transport, we were able to organise a speedy evacuation process. What occurred next simply could not be scripted. Somehow, with the assistance of fellow volunteers, we were able to lift the patient onto a dining table which we used as our “stretcher”. We then carried the patient out to our awaiting “ambulance” which was the back of someone’s ute. Just as we left the building, the heaven’s opened and it began to bucket down with torrential rain. I was drenched, but completely unfazed. We had an IV line, we had already given aspirin and 18mg of morphine as well as an anti-emetic in case the patient got nauseous. We had a defibrillator and I felt that Neil and I could cope with any eventuality. (although I was a little nervous about having to use the defibrillator- we were absolutely soaked and the thought of using an electrical current gave me pause). In fact, I was so unperturbed that at one stage I thought to myself “My gosh, these South African men are just gorgeous, I wish I was 10 years younger” (now that’s disturbing, but remember I have been through 5 months of a complete man drought) With the three of us cramped in the back of the ute, we drove to the South African border. We were met by some Advanced care paramedics (again, ruggedly handsome) and we safely transferred the patient into their care. Although the diagnosis is still uncertain, we heard today that the patient is doing well.
We haven’t had quite that level of excitement since, but Neil and I have spent the rest of our time at the abandoned hospital here. Our challenge over the next 2 weeks is to try and sort the place out. It was abandoned suddenly and there is a lot of equipment and resources that can be used elsewhere. The project is enormous and I doubt we will get through it in time. The problem is, the hospital received an enormous amount of international donations and most of it is completely inappropriate for the medical care we are able to provide here in Swaziland. Incredibly sophisticated pieces of equipment- hundreds of central venous lines, instruments for incredibly complex surgical procedures and even catheters for angiograms and other invasive diagnostic procedures. I know all of this was donated with generosity and kindness, but honestly, here in Swaziland, with our basic provision of health care, all of this is redundant. We have had to dump hundreds of thousands of dollars of resources simply because we cannot use them here. It breaks my heart. That being said, we have been able to salvage a lot of resources that will be invaluable to the Good Shepherd, so not all is lost. A lot of the equipment is from America and is 110 voltz. Here in Swaziland, we have 240 voltz, but some of the equipment may be able to be converted although it will be at great expense. When we have sorted out the resources, we plan to set up an emergency room here at Bulembu and then we will write protocols and train the nurses here to provide simple emergency care. This is a huge undertaking and perhaps overly ambitious for a two week project.
Not all of my time is spent working. I have been able to spend time with my beloved orphans. The babies are cute, but I prefer to spend my time with the 5 children aged 3-4 years. They have got to know me during my visits to Bulembu and we have established a close relationship. I spend hours playing with them, being the recipient of many cuddles and kisses and generally having the time of my life. I am completely and utterly in love with these children. I know my heart is going to be broken when I leave. This afternoon, I spent 3 hours with them. I sang nursery rhymes to them, helped them name Australian and African animals and helped them with colouring in. I don’t think I have felt this happy and this content for a very long time. They are beautifully behaved children and each take turns for their special “cuddle time” with their Aunty Melanie. I am never without a child in my lap or in my arms. I am absolutely delighted that their favourite show on TV is “Hi-5”. This is an Australian production and thanks to my many years as a babysitter I am very familiar with all the songs. We danced and sang and I delighted in the fact that no matter where you are in the world, all children are generally the same. We are all humanity. We all want to be loved, we all want to be able to express ourselves and we all want the freedom to do so.
I truly feel like the luckiest girl in the world to have this experience. Whilst I do feel bad about abandoning Good Shepherd early (and I know they are upset with me), I feel like I can truly enjoy the rest of my time here in Swaziland. I have temporarily escaped the devastation and for that, I am truly grateful.

Thanksgiving

2008-12-01T23:04:00.000-08:00

I like to think of myself as a very patriot Australian, but on Thursday, the day of Thanksgiving, I was proud to consider myself a temporary “American”. My best friend is American and in the past 6 years, I have visited the country 7 times, so I think I have a good appreciation of the culture and especially the significance of Thanksgiving.
Given that I am the sole Australian amongst a large group of American volunteers, I was particularly keen to show just how “American” I could be. I asked Courtney for her recipe for Pumpkin Pie as I was determined that this would be my contribution towards the festivities. Thanks to a trip into Manzini, I was able to source all the ingredients and I have to admit, the dessert turned out spectacularly and was one of the highlights of our celebration.
We all went to great lengths to obtain a turkey and I have to admit, Susan was the one who came up trumps. She got her hands on a 20lb (~10kg) bird that was killed and plucked the day before we tried to squeeze it into the oven. The turkey was the best I have ever tasted- perhaps due to its “freshness” and the fact that we had to “google” cooking times because none of us had ever cooked a turkey before.
The event turned into something much bigger than we ever imagined. Somehow, we ended up having two more Peace Corp volunteers join us as well as two other Americans that had arrived the day before to volunteer at the Good Shepherd for 12 months. It was a wonderful way for them to begin their stay. We also invited all the other doctors from the hospital and in total, we catered for about 25 people. It was very festive and everyone had a good time. Krisitin made her traditional dish of sweet potato combined with cranberries, cinnamon and marshmallow and whilst I was initially sceptical, I can now assure you that I am a definite convert to this unusual dish. She also made pumpkin cookies with cream cheese frosting (absolutely divine), whilst Chris cooked great mashed potatoes and Susan provided our vegetables. We had a lot of fun preparing the foods together and I will forever remember the “sisterhood” and “camaraderie” we felt as we tried to create a traditional American experience. Susan said it was perhaps the best Thanksgiving she had ever experienced, whilst it was unanimously voted that the pumpkin pies I made were the very best anyone had ever tasted (THANK YOU COURTNEY!). It was also an emotional night for all of us as it was my last night at Good Shepherd. I cried my eyes out when Dr Pons said grace and I also shed a tear when, at the end of the evening, it was just me and the true Americans. We sat in a circle and each spoke about 5 things we were truly grateful for. It was an incredibly special moment and something I will remember forever. Each of us had different things to say and each were deeply personal and meaningful. In summary (and you certainly get the abbreviated form), the five things I was most grateful for include:
My incredible family who have provided me with enormous support and encouragement and who didn’t think twice about coming all the way to Swaziland to see me whilst I am here.
My friends in America, Australia, Ireland and England who have emailed me, written to me, sent me letters and parcels and have put up with moments where I have almost gone insane whilst being in Swaziland.
My experience whilst being here in Swaziland. Even though it has been the most challenging and difficult experience of my life, I have learnt a lot about myself and the world around me and I think this makes for one extraordinary life.
The fact that I am a doctor and have been able to make a difference in peoples’ lives despite the lack of resources available to me.
My hair straightner- my experience here would have been a lot worse if I had to endure my “birds nest” hair.

My last Monday at GSH

2008-11-25T02:10:00.000-08:00

Mondays in any medical setting are notoriously busy. I always start Mondays here with a sense of dread. Who died over the weekend and what new admissions await me?
Yesterday was by far the worst Monday I have experienced so far. Rather ironic that it just so happens to be my last. I had 16 new admissions over the weekend and this was in addition to the 20 or so that I already had on the ward. All the new patients had HIV, all were critically unwell and all required complex management plans that took me hours to organise. For the first time ever, I started to get really cranky at my nurses- something I have always prided myself on not doing. During the ward round, two of my patients died. One was 20 years old, had AIDS and presumably died of meningitis. Her neck was so stiff that when I went to lift her head off the bed, the rest of her body came up with her. The medical term for this is nuchal rigidity and I have never seen it quite as profoundly as what we see here. The second patient, also in her 20s also died from an AIDS related illness. I wish I could eloquently describe the feelings that emerge inside of me when I face days like this, but I am unable to put into words the series of emotions that leave me with an utter sense of despair.

Last night, as I lay on my bed, just staring at the ceiling, I started to think about what constitutes a “disaster”. When a bus crashes and people are killed, the news headlines read “Disaster”. When kids in China are poisoned with melamine, we call this a “disaster”. When the economy crashes and people have to tighten their belts a bit, we call this a “disaster”. I don’t want to trivialise these issues, because to the individual, these are important- but what do I call what’s happening here?
I’m working in a hospital where 100% of my patients have AIDS. They are suffering shocking conditions that we don’t always have the resources to adequately investigate or treat. We are now overcrowded and have to turn sick people away because we have run out of beds and floor space. We’ve even run out of sheets to put on the beds. Now most of my patients are between 20 and 30 years old. Most have children that will be left without a mother when my patient dies. Even if I manage to improve my patients’ condition, they are discharged home where they struggle daily to access food and water. They often can’t afford the medications that I prescribe them to keep them well. They can’t afford to pay for transport to come back for a review visit so that I can try and keep them well.
So I ask you, why then is this not on the front page of the newspaper and quoted to be a “disaster”? What needs to happen further before we realise that the lives lost here are just as important as the lives lost anywhere else in the world? I don’t understand why the world is not screaming out about the injustices that allow almost 50% of a population to be afflicted with the one disease.

Then I am faced with my own sense of guilt, because I am abandoning what I consider a disaster. Does this not make me as guilty as the rest of the world that chooses to turn the other way instead of facing the reality of this disaster here in Swaziland? But the reality is, I cannot face the pervasive smell of death any more. I’m not sure when the time will come when I can close my eyes at night and not see the bodies of my patients, emaciated, covered in fungal skin conditions and languishing in their own excretement. I don’t know when I will not be able to hear their cries and their desperate pleas to me to ease their suffering. I don’t know when I will ever truly state that I have any sense of hope for Swaziland.

I usually spend Monday evenings with the Pons’. I called them and told them that I wasn’t able to make it last night. I felt so completely depleted. At Helen’s insistence, I ended up going and I am pleased that I did so, because I felt a lot better afterwards. The Pons’ have been incredibly kind and generous towards me during my stay in Swaziland. Helen has become a particularly valued friend and she has provided me with a great deal of compassion and comfort that I will always be grateful for. At the end of the evening I brought home a companion called Ginger. He’s the kitten that belongs to the youngest Pons- Ruth. They are going away for a few days and they asked me to care for the tiny animal. He’s ginger (duh!) and has the most magnificent blue eyes. He is about 5 weeks old and no bigger than the size of my hand. I am completely in love with him and I think he feels the same way about me. I really like cats, but I have resisted the temptation to get my own as I have always felt that this would cement my future as a spinster. It seems that in my experience, all spinsters tend to have a cat and I am determined not to follow a similar fate. I do, however, feel that this is only a temporary arrangement and therefore unlikely to have a negative impact on my marriage prospects. However, I went back to check on him after my ward round and I was rather disturbed to find him playing with the strap of my bra that I had left out to dry. Whilst you may not find this anything to be disturbed about, this actual event is not the first time that an animal has taken a liking to my unmentionables. Last year, I looked after a dog, called Patrick, when his owners went overseas for a holiday. Patrick had the rather disturbing habit of going into my wash basket, selecting out my underwear and distributing it throughout the house. I believe he actually buried one of my particularly expensive bras, because I searched everywhere for that item and it was never to be found. So, it is with this new piece of animal evidence that I have concluded that the reason I can’t attract men is the fact that I must be secreting a pheromone that attracts animals only. Now I thought Africa was the only thing that had problems……

New contact details

2008-11-23T01:16:00.000-08:00

The computer at Good Shepherd has a virus and has crashed in a big way. I can no longer receive emails at doctors@realnet.co.sz
If you would like to contact me, please email
melanieunderwood6@hotmail.com

One more week to go at Good Shepherd

2008-11-22T11:15:00.000-08:00

It seems that despite only having one more week at Good Shepherd, I am going to be challenged right up until the very end.
It’s been a disastrous week in terms of what has been happening on my ward. Multiple deaths on a daily basis. On one day, I had 4 die within hours of each other and I was devastated. I started to question my ability and started wondering what I was doing wrong. In a moment of clarity, I was able to recognise that all these patients were incredibly sick with advanced AIDS and horrendous complications and no matter how much I fought for their lives, they were going to die anyway. It still doesn’t make it any easier.

I gave my nurses their last tutorial on Friday morning and I can’t help but feel that I am “abandoning them”. We have worked hard together and we have developed systems that have truly had a positive impact on patient care. I know that this will all inevitably fall apart once I leave as there will only be one physician to run both male wards/female wards and outpatients. An almost impossible task.

Julia returned to the USA on Thursday and we feel like we have lost a member of our family. She was one of the most incredible people I have ever had the privilege of meeting. At 23 years of age, she finished nursing school and came straight to Swaziland. An enormously courageous and selfless thing to do. She had been here for 12 months and during that time she integrated herself into the Swazi community by learning their language, immersing herself in their culture and dedicating herself to caring for the sick and destitute. She was also an incredible friend to me- her support and encouragement was invaluable. We shared many laughs and many tears and I feel a connection with her that will last a lifetime. I am so excited to see what her future holds as I know she is going to embark on more adventures that will lead to a truly extraordinary life.

By Friday, I was starting to feel completely depleted of any reserve to continue caring for my patients. I finished my ward round and then retreated to have a good cry. Thankfully, Susan informed me that she was going to Mbabane for a meeting and she asked me if I would like to join her. Being a volunteer, I have the freedom to say “I’m not coming to outpatients today”, so I happily accepted her invitation and we made our way into the capital city. We had a pleasant lunch and then made our way to one of the big hotels that was hosting a guest speaker from the USA. Her name was Dr Wafaa El-Sadr and she is the international director for ICAP (International Centre for AIDS care and treatment programmes). She is an infectious disease specialist who works at Harlem Hospital in New York under the auspices of Columbia University. She is an international expert on AIDS. She was giving a talk on AIDS and anti-retroviral treatment and she discussed the recent results of a huge international study called the SMART study. I listened to her in complete awe. It has been so long since I have been in an academic environment and I relished the opportunity to hear of her talking about disease, epidemiology, drug treatment and hopes for the future of AIDS. She must have noticed my enthusiasm for what she was saying because she came up to me after the talk and I introduced myself as an Australian doing my small part against AIDS here in Swaziland. She was very gracious and polite (and tried to convince me to give up emergency medicine and become involved in public health) and I found myself to be quite overwhelmed by being in her presence. I know this will sound absolutely ridiculous for some of you, but in medicine, there are some people who we consider “gurus” and I know she is one of them. I felt like I was in the company of a “super star”.
Susan and I felt re-invigorated that despite the hopelessness we see here, on an international scale, there is still a lot of passionate work being done to combat this disease.

By this stage it was about 7.30pm and we faced the dilemma of whether to drive back to Good Shepherd or stay in Mbabane for the night. We have been constantly advised not to drive in Swaziland at night as it is considered extremely dangerous. Despite the normal dangers of poor roads, the ever present cattle and goats that meander across the roads and the fact that no one here pays any attention to road rules or speed limits, we were also faced with poor visibility. However, I have not received any income since the beginning of July and my finances are starting to dwindle, so I was reluctant to stay in a hotel overnight. Susan was also keen to get home and she thought she was capable of safely navigating her way back to Good Shepherd. So we set out in the dark and I have to admit I was hyper-vigilant and nervous. Susan was extremely careful and as we made it closer to Siteki, I started to feel reassured that we would be OK. The reassurance did not last for long. We were within about 10 kilometres from home when a car recklessly came out in front of us and Susan had to suddenly slam the brakes and swerve off the road to avoid a collision. It was simply terrifying and we were physically and emotionally shaken. The rest of our trip was in silence as we both reflected on what could have occurred. There is no doubt in our minds that if Susan had not been so alert and her reflexes not so quick, we would have been in the midst of a disaster. There are no ambulance services here in Swaziland. The facilities here at Good Shepherd- if we had made it to a hospital alive- would have been inadequate to deal with severe trauma. We have run out of blood here, so if we needed a blood transfusion, we would not have had any blood available. I know these are all “ifs” but the reality is, we came close to tragedy that could have been avoided. I cannot imagine putting my parents through the agony of coming to Swaziland to collect my body and I am just so grateful that we escaped this event without us being hurt. I vow that for the remainder of my time here, I will not get into a vehicle at night. It’s just not worth the possible consequences.

I’ve decided to have a quite weekend and stay around at Good Shepherd. My tasks for this weekend are to write my Christmas cards and start packing some things up in preparation for my departure to Bulembu. I’m not exactly sure how I am getting to Bulembu, but at the moment it looks like I will be going on a truck that will be taking maize from Siteki to Bulembu. I’m just appreciative of any mode of transport. I will be coming back to Good Shepherd for a few days in December. I have offered to do ward rounds from the 22nd-25th of December whilst I am here with my family. It will give my family the opportunity to witness first hand the work I have been doing here and I know we are extremely short staffed during this time and my assistance will be appreciated.

It’s hard to believe my family will be here in 3 weeks. I know they are incredibly excited. Graeme (my step Dad) has had his bags packed for a month already and my mother is trying her best to get everything organised so that the various donations that she has received can be transferred here safely. She tells me that a number of you have been extraordinarily generous and I just cannot tell you how much I appreciate your generosity. Pleased be assured that you are truly making a worthwhile contribution and your donations will have an enormous impact.

Royal Swazi Spa

2008-11-17T06:30:00.000-08:00

Yesterday marked exactly 4 weeks until Mum, Graeme (my step-dad) and sister, Rachel arrive. Let me tell you, I am counting down the days. I cannot wait to see them. Not only will it be great to show them Swaziland, but it will also mean that I am one step closer to going home to Australia. I am ready to go home. I don’t know how much more fortitude I have left. I’ve even decided that I’m probably not even going to bother telling you of all the despair I see on a daily basis- you’re probably tired of it. I know I am.
The weekend was good. Saturday was Julia’s last weekend in Swaziland and we wanted to make it special for her before she returns to the States on Thursday. She rented out a cottage on Mabuda Farm and she invited Chris, Susan and I there as well as 6 local boys (aged 8-16). She has held a “games night” every Friday for these boys for the past 12 months she has been here and she wanted to give them a treat as her departing gift. They swam in the pool (I just potted around with the horses, cows and kittens) and then we all had a braai (African style BBQ) for dinner. Susan brought her laptop and iPod along and we were able to listen to some music. I cannot tell you how uplifting it was for me to hear music- it has been a very long time and I miss the enjoyment it gives me. Susan had some Motown on her playlist and I actually got up and had a little dance. I was just so happy! The beauty about my time here in Swaziland is that I have been completely uninhibited in just being myself. I can listen to daggy music and my friends here still think I’m pretty cool. I can openly admit that I think “The Sound of Music” is the best film ever made and no one rolls their eyes. I wear my ordinary clothes and my nurses think I have the most fashionable wardrobe in the country. The love my friends have for me is unconditional and it’s liberating to just be myself without having people trying to “improve me” or show me how to be more fashionable or what music I would be “cooler” to listen to.
We had fun with the group of boys- we simply had a few balloons that we spent ages trying to keep in the air. We danced and I even taught them Australian anthem and “Give me a home amongst the gum trees…”

On Sunday, 6 of us crowded into Susan’s small, 5 seater Micra to go to Manzini. Incredibly dangerous, but given that the locals pile into the back of utes and trucks etc- when in Rome…..
Thankfully we arrived safely. Kristen and Andrew had to go to a Peace Corp function whilst Chris, Julia, Susan and I went onto the “Royal Swazi Spa” Let me tell you, this place is not representative of Swaziland- it is over the top opulence and it was fabulous. It just screams luxury and I actually felt somewhat out of place. This discomfort soon vanished when I was served my cappuccino in the fine china (hooray- my stomach has now settled enough tolerate it) and then I enjoyed my salad with grilled houlumi cheese. The piece de resistance was the spa. I was desperate to have some waxing done and I took my chances to see if they had an appointment at short notice. I nearly jumped for joy when they took me into the sanctuary where the lighting was dim, soft music was filtered through the rooms and the colours all muted and inviting. It really is a shame that instead of having a massage, facial, total body exfoliation or body wrap, I had hair ripped out of me, but let me tell you- I felt like a new woman afterwards. I felt somewhat ashamed that such an unnecessary indulgence made me feel so good, but it has been hard on me not having me usual creature comforts I have back at home (I suspect it has been hard on my local beauty salon back home not having my regular patronage). It really was a lovely day and something I will remember fondly.
Shame I had to come back to work….

A day with Home Based Care

2008-11-13T10:02:00.000-08:00

Today I had the unique experience of joining Julia on her daily routine with a programme called Home Based Care. I did my ward round and joined her team when they headed out later in the morning.
Home Based Care involves going out to local homes and providing basic medical care and food to the disadvantaged who don’t have the means of getting to Good Shepherd or who have chronic conditions requiring a nurse to check up on them. We have similar care in Australia, the UK and USA. However, like everything here in Swaziland, it’s a little different.
Firstly, the people we visited were simply the poorest people I have ever seen. They have nothing- a few rags they use as clothing, a few basic items that allow them to make a fire and cook food, but otherwise- not much else. They walk kilometres everyday to obtain water and their existence truly is based around survival. And yet, despite these extraordinary circumstances, they always had a smile to share with us and it warmed my heart to see their courage and stamina.
Their homes are made out of sticks and mud. The floor is made out of cow dung. In fact, in one of the homes, I was able to watch one of the women “relaying the floor”. You mix cow dung with water and compact it down to make a smooth surface. Once it dries, it actually makes quite a stable surface. It has been raining a lot here recently and I am continually caked in mud, but these floors seem to resist being formed into a mud pies.
The houses are very smoky because people have open fires in them which they cook on. (the fires are also responsible for the large amount of burns we see here at Good Shepherd). Sometimes, if they had more money, they had a mattress to sleep on, but this is not always available.
Many of the people we visited had AIDS. As I have mentioned previously, if you are poor and have AIDS, the World Food Programme provides you with some staple nutrition (however, the WFP doesn’t reach everyone and we must not forget that many, many people here are starving and malnourished.). We handed out packets of corn-soya, maize meal, peanuts, salt, sugar and soap. Some lucky families were the recipients of some milk. Whilst it is very satisfying to be able to provide medication to the sick, I have to admit, I found it more fulfilling to give food to the poor. We all take food for granted and yet these people don’t know from one day to the next if they are going to eat. I can’t imagine what that must feel like- especially for the AIDS patients who do happen to be lucky enough to be on ARVs- these drugs can make you feel awful with debilitating nausea, so I can’t imagine what it would be like to have the side-effects from these drugs and also be hungry….
There were a lot of children around- almost all of them with little pot bellies that are a sign of Kwashiorkor (a diet that is deficient in protein). They were simply delightful and loved having their photo taken. Again, extremely impoverished- some without clothing. Continuous stream of nasal discharge that attracted the flies and yet they seemed happy enough. Perhaps it was just the excitement of seeing our vehicle and knowing it was bringing food.
I actually got to tend to some sick people. Very different circumstances to what I would experience in a clinic or hospital. I sat on the floor to examine them, took blood pressures whilst sitting on a log and I even examined a man’s penis behind our truck. He had some genital lesion that I didn’t have a clue what it was, but I was able to give him some basic antibiotics. We told him that he needed to use a condom otherwise he would infect his wife. He told us that he went to a nearby clinic and that they had run out of condoms! They wonder why Swaziland has the highest incidence of HIV in the world??!!
We were also able to administer simple analgesia, basic antibiotics, multivitamins and some other basic health care supplies. All of this was free thanks to kind Americans who donate to support this programme. These people would receive no other health care otherwise.
I came home exhausted, covered in dirt and yet extremely humbled that I was privileged enough to be part of this programme- even if it was only for a day.

Some divine intervention

2008-11-12T07:40:00.000-08:00

I think I have begun every blog entry recently with “It’s been another difficult week”. I wonder if you are getting bored with my constant tales of misery and despair.
The abdominal pain has settled somewhat but I am still unable to eat certain foods. Of most concern is my inability to tolerate coffee. I tried it on Monday and found myself rolling around in agony. I know I initially complained about the coffee here, but thanks to Courtney and my step-Dad sending me copious amounts it, I have been able to enjoy my only real “vice”. Up until now that is.
I spent all weekend in bed and had plenty of time to reflect on my time in Swaziland and what the experience has done for me. Unfortunately at the moment, I am consumed by the daily despair I pay witness to and it has taken a huge toll on my mental health. I can’t remember feeling this depressed before. I know that once I get home to my familiar surroundings and support, I will look back on this experience as being one of the greatest of my life. It has challenged me and no doubt enriched me as a person. I just can’t really appreciate that at the moment. The truth is, some of my despair comes from the fact that I had such high expectations of Swaziland. I thought that by coming to a third world country and serving the poor, I would find my purpose in life. I would be able to justify why at 30 I’m single and childless. I truly believed that I was in this situation because there were “big plans” for me and these plans required me to be footloose and fancy free.
The reality is that I don’t think I can do this job long term. I feel like some of my soul has been destroyed whilst being here. My innocence and enduring optimism has been eroded somewhat. It’s ironic that last week Susan described me as “Chicken soup for the soul” and yet all I could think about was how I had lost mine.
Nevertheless, within 24 hours of emailing a friend and having a major catharsis of emotions that I think made me look like a raving lunatic, I find that an opportunity has opened up that will allow me to leave the despair of the female ward a little earlier.
Bulembu is hosting a massive project called “Swazi 1000”. I’m not entirely sure of the exact details but I do know that about 1000 college students are going to descend on Bulembu to devote two weeks to reconstruction of houses that will eventually house orphans. With such an enormous undertaking and some of the projects potentially dangerous, they require a doctor and the Board members have asked me to be there for the two weeks. I am delighted to help out. I will step back into my role as an “emergency doctor” and I will be on hand to manage anything that happens to the group of people who will be aged 16-24. This means I will be treating healthy people who don’t have AIDS. I will also get to see this massive project unfold which will be exciting and give me further hope for this project that I am passionate about. I will also be able to go and cuddle an orphan everyday and I think this will be the best therapy for me at this time.
I now have two weeks left at Good Shepherd and hopefully I can make the most of my short time left here.

It's enough to give me an ulcer....

2008-11-08T02:07:00.000-08:00

It had to happen sooner or later- I have been so lucky so far, but this week, I got sick.
It started by waking me up at 2am on the morning of the election. My stomach was aching and I had overwhelming nausea. I couldn’t even eat the pancakes that Kristin and Andrew made me. For those of you who know my eating habits intimately, you would know that this was a clear signal that things weren’t right- pancakes are one of my favourite foods.
Anyway, for the rest of the day I couldn’t eat. My abdomen ached in a way that I have never experienced before. It was a deep boring pain and associated with shocking nausea. Anytime I attempted to eat food or drink liquid, I would be rolling around in agony about an hour later. So I stopped eating and I stopped drinking. All I could do was lie in bed- but only in one position because if my stomach came into contact with the back of my abdominal wall, I was in agony.
Chris came over and examined me. My abdomen was distended like a balloon and when Chris palpated my abdomen I nearly jumped off the bed. We both came to the conclusion that I may have a stomach/duodenal ulcer. She went in search of a drug called omeprazole and by some miracle, she was able to put her hands on some. It was difficult keeping the drug down but I managed to get a decent dose in. I woke up the next morning feeling a little better and I foolishly went in and did my ward round. By the end of it, I could barely stand. I was in agony. Chris and I started to worry a little bit and we made contingency plans of what to do if things got serious. I was adamant, that despite the fact I had developed some very mild malaena (suggesting that I was bleeding in the stomach), I did not want a blood transfusion even if I was really unwell. I am not morally opposed to blood transfusions- I simply don’t trust the blood here to be free from HIV. We would not stop for help in Swaziland but simply go straight to South Africa. Thankfully, we did not have to enact these plans, because regular doses of the omeprazole seemed to work over the next two days. I stayed in bed, remained nil by mouth and slowly improved. Chris checked on me regularly. Last night, she was absolutely gorgeous. She made me a clear soup and I was able to tolerate a few mouthfuls. It was delicious, very simple and very much needed because I was dehydrated and weak. It was this simple, random act of kindness that helped improve me dramatically. I’ve been able to have more and more of this soup and I now feel much better. I still have a constant, dull ache in my stomach but I’m able to get out of bed, I’m able to tolerate fluids and I feel much better within myself. I think I may have dodged a bullet….
I am very well aware that this presumed ulcer is probably due to stress, otherwise it could be a big parasite growing in my stomach…..
I’m not sure what to do about the stress. I certainly have tremendous support from my friends here. Courtney emails me everyday and I get a great deal of comfort from her predictable contact. I just think that what I witness here is stressful. For instance, I often have people join me for my ward rounds. Kristin and Susan (both nurses) have joined me and both have been incredibly distressed at what they witnessed. I have a young Swazi girl who has completed a Bachelor of Science and has applied to do medicine. She asked to join me on my rounds so that she could get a taste of what medicine is like. I have tried to be an enthusiastic role model for her, but she has often been reduced to tears at what she sees. Other people have vomited on ward rounds and earlier this week, I had a young girl from the Netherlands faint whilst we were seeing patients. I think these reactions are normal for what we are seeing here. It is distressing, it’s almost surreal and the reaction we have to the suffering is visceral.
Also contributing to my stress is the ever present fear of snakes. A huge Black Mamba was found in the female ward earlier this week. Thank God I was not there to witness the chaos and hysteria that ensued.
Last night, one of the security guards knocked on my door and he warned me that a huge snake was found behind my house yesterday. He warned me that I need to keep all my doors and windows closed and make a lot of noise as I exit my flat.
If that isn’t enough reason to develop an ulcer, I don’t know what it.

Hoorah for Obama!

2008-11-05T07:00:00.000-08:00

Hallelujah, the world, for a small amount of time made sense again!
I was woken early by Susan this morning. Her friend in San Francisco called to say that Obama had won the election and Susan immediately called me. I wasn’t entirely convinced at first as it seemed pretty early to be making an announcement, but within an hour, I was in front of a TV watching the broadcast on CNN. Kristin, Andrew, Susan and I were in high spirits as we made pancakes and watched the coverage. We saw the re-run of Obama giving his acceptance speech and we all knew that we would probably remember this moment in history for the rest of our lives. Susan was crying and I was just mesmerised. I actually find men who are smart, articulate and good public speakers to be absolutely intoxicating and despite the fact he’s a married man- I LOVE OBAMA! A few of you will be perplexed by my enthusiasm for an American President, but I really feel that we live in a global community and what happens in one country (especially one as powerful as the US) affects us all throughout the world. Here in Swaziland, where there is no hope, I desperately needed to hear the message of hope and I think Obama delivered that for me. I also know that my best friend Courtney, and her family and friends have the comfort of a promising future and that’s really important to me.

So it was with this renewed enthusiasm and hope that I entered my ward to do a delayed ward round. All that hope and enthusiasm disappeared within minutes and I was confronted with the stark reality of my existence in Swaziland. I have some really sick women on the ward at the moment. Women who just consist of skin, bones and a vacant stare that signals that their time here on earth is limited. They have no immune systems and they are covered in skin infections and tumours. They are just lying there, unable to even roll over to change positions because they are so weak. I felt overwhelming hopelessness.
This feeling was compounded by the fact that things here at Good Shepherd are deteriorating. We have no reagents to do a complete blood count. We have no India Ink to look for Cryptococcus on cerebral spinal fluid (In patients with AIDS, it is incredibly important as many patients get meningitis and it’s important to be able to tell the difference between a bacterial meningitis and a fungal meningitis called cryptococcal). We don’t have the reagents to test for syphilis (again, very common here). We are starting to run out of a powerful antibiotic called ceftriaxone which I use effectively for many of my patients. Yesterday we ran out of sputum cups so I was unable to test for tuberculosis which is in epidemic proportions here. I am so incredibly frustrated and upset that I actually feel I would be better off just getting on a plane and coming home. This is all so difficult and no hope of improvement is in sight.
Today, for the first time in my career so far, I let my hostility out on a patient and I feel incredibly guilty about it. I was seeing one of my patients who was diagnosed with HIV on admission. I had spoken to her about the diagnosis and its implications yesterday. Today she asked to be discharged and when I asked her about how she would follow up on her CD4 count, she told me (through an interpreter) that she thought I was lying by telling her she had HIV, she thought she had malaria and I had got the diagnosis wrong . First of all I was a little insulted that any patient would think I would lie to them and secondly I was just filled with enormous frustration that despite the fact that Swaziland has the highest incidence of HIV in the world, people still will not accept it as a problem here. I went up close to the woman and pointed to a patient in the bed opposite to her. The woman in the other bed has AIDS with a CD4 count of 1. She is incredibly emaciated and semi-comatose with shallow end-of-life respirations. I pointed to the patient in the other bed and said “If you do not accept you have HIV and you do not follow up on the recommended treatment, you will end up looking like her!” Perhaps my voice was raised a little because in the ensuing silence, you could have heard a pin drop. I think I shocked the nurses with my outburst. I am not proud of my performance. I was just so frustrated that I allowed by emotions to overcome my professionalism. The patient with newly diagnosed HIV was very upset with me and I know that I behaved very badly and inappropriately as far as Swazi culture is concerned. I apologised and moved on. I could not continue to argue with this patient. Her non-acceptance of the situation is reflective of most of the attitudes here. People present here at a very late stage of their illness and I am often left with hopeless situation of applying a “band aid” to give them some quality of life for their last months on earth. Because people present so late, we are often unable to effectively give anti-retroviral treatment. Many people who commence ARVs die within the first 6 months of their commencement.
So whilst the US may have gained some much needed renewed hope, I am afraid that this is not the situation here in Swaziland. My joy was short lived. Tonight I am going to Chris’s for her infamous Cincinnatti chilli, perhaps this will cheer me up.

Melanie in Manzini

2008-11-02T08:06:00.000-08:00

I have no idea whether I will ever be able to publish this blog entry. It is sweltering hot and the winds are cyclonic and this means one thing: the electricity goes off for a few seconds every couple of minutes and I lose everything I have done on the computer. I’m typing in a word document and saving as I go, but who knows if I will ever make it onto the internet….

Yesterday started well. Susan woke me at 8am and asked if I wanted to go into Manzini- did she really need to ask?! I haven’t been out of Siteki for over a month, so I was desperate for some time away. I called Chris and like me- she started squealing with delight. We were really hoping that this would be the weekend where we would be able to “escape”. Susan will be working here for a year and she actually gets paid to do her project here, so we thought all our Christmas’s had come at once when she purchased her own vehicle last week.

I spent my morning preparing for my big trip into the “metropolis”. I shaved my legs, wore my $50 pink lace French knickers and applied mascara. I felt a hundred times better than what I had during the week. For my male readers, the significance of all this will probably elude you, but hopefully my female readers will be able to appreciate just how uplifting a little bit of primping can be.
There were four of us that ended up going on the “big trip” Susan, Chris, Kristin and myself. (If any of you are wondering why I haven’t mentioned Julia in a while, it’s because she is holidaying in Uganda with Farrah and Emerald. She returns on Friday).
The first place we visited was our usual “haunt” at Swazi Candles. We enjoyed a beautiful lunch and the girls kept remarking just how contented I looked. My joys in life are simple- beautiful scenery, good coffee and the company of friends.
We then went in search of gifts for Christmas presents and I was delighted to find some Christmas cards that I will have to send off soon. We finished our day by going to our favourite supermarket- “Pick n Pay” where I was able to buy some of my luxury items that I am unable to buy in Siteki. The day was fabulous but a little overwhelming. On the drive back home, I developed a migraine and by the time I got home, I was a mess. Nevertheless, a few drugs and a good night sleep later, I woke up this morning feeling much better. I have spent the day reading some gossip magazines that my best friend Courtney sent me from the States. It reminded me of just how far away I am from the reality of the Western world. I feel very torn between the “two worlds” I have been living in. I’m working in remote Africa and at the same time, I’m reading about Britney, Jennifer and Angelina. I really have no idea how I’m going to adapt once I return to Australia.

Speaking of which, today marks exactly 6 weeks until Mum, Graeme (my step-dad) and my sister Rachel arrive. I cannot wait to show them Swaziland. We have planned a holiday in South Africa, but before that, we are going to do some volunteer work in Swaziland. We are going to volunteer our services at the orphanage in Bulembu for a few days and then we are coming back to Siteki and organising a day camp for a group of orphans. We hope to spread a bit of Christmas cheer amongst those who are not as fortunate as us.

Speaking of Christmas cheer, I would like to make a special request to you all. From reading of my adventures in Swaziland, it would be obvious that I am a passionate supporter of the orphanage in Bulembu. From all the places of need that I have visited, I am convinced that this is the place that offers the most hope for the vulnerable children of Swaziland. I have witnessed first hand the amazing work these people are doing. I have seen with my own eyes just how well nourished, loved and nurtured these orphans are. Just last week, the orphanage received 3 more orphans. They now have 14 babies, 19 toddlers and 5 children aged 3-4 years. The workers there are committed to the children, their health, their spiritual growth and encouraging their Swazi culture. I truly believe that this place has the potential to offer hope to future generations of Swaziland. I would like to help them by asking you for a monetary donation. They are struggling financially to cope with the increasing demands of looking after 38 young children. For example, they go through 8kg of washing powder each week. (all babies wear cloth nappies and in addition to all the clothing and bed linen, this makes for endless loads of washing!). They need money to buy bread, peanut butter, formula, cereal, nappy rash cream etc, etc. They also need money to employ the Swazi women who are there to feed, burp and change all the babies. They rely solely on donations- they do not receive any government support. Sending items is too expensive and difficult to actually get to this location, but all the above items can be purchased in Manzini and my family and I will purchase these and take the items to Bulembu.
After a discussion with my family we have decided that the best way to co-ordinate this is the following:
Send a cheque to:

Sally Woodings
7 Stowe Court
Forest Lake 4078
Queensland
Australia
+61 7 3879 7662
Email: wood121b@bigpond.net.au

If you would like to donate cash, then you can contact my parents and they will organise to collect the money from you.
As soon as my Mum receives the cash/cheque, she will issue you with a receipt. (please send put your address on the back of the envelope)
Mum will cash the cheques and transfer them into South African rand (this is the most economical way of handling money in Swaziland)
Once we reach Bulembu, we will have Robyn, who runs the orphanage, write an individual receipt to each of you on behalf of ABC ministries.
I can promise you that every cent that is donated will go to those orphans. I know with Christmas approaching there are any demands on the family budget, but believe me, here in Africa, even the smallest amount of money can go a long way. I ask you to please consider giving to this amazing charity.
Anyway, another week is about to start at Good Shepherd and who knows what I will be challenged with. Stay tuned.

Melanie's musings

2008-10-31T08:44:00.000-07:00

Today was a huge day here at Good Shepherd. The “newly elected” (ie chosen by the King) Prime Minister and Health Minister came out to see the hard workers at one of their leading hospitals. The place was like a circus with people running around like lunatics trying to make the place look better than it actually is. Meanwhile, Chris and I spent our time hidden away in the hospital actually seeing patients. It seems ironic that as the only two staff members who aren’t paid to work here, we were the only ones who were working and not watching various speeches given by Ministers who didn’t actually step a foot in the actual hospital. I shouldn’t be so cynical- I know this happens with politicians everywhere in the world. However, I want to give you a “behind the scenes” insight as to what was actually happening behind all the pomp and ceremony.

I woke up early this morning. On Fridays I give the nurses a tutorial at 7am. I had a splitting headache and for a moment, it crossed my mind that I may have meningitis. I then reminded myself that I don’t have AIDS and despite the fact I have many cases of meningitis on the ward, it is uncommon to get the disease if you have an intact immune system.
I entered the ward and was nauseated by the smell of faecal material. One of my women, who has been with me well over a month, has shocking diarrhoea and the faecal material had leaked out of her incontinence pad and smeared every surface surrounding her. She has advanced AIDS and can barely roll over because she is so weak. Her family have abandoned her and I have no where to send her for her final stages of life. She will probably spend her last amount of time on earth lying perilously in her own excrement.
I then started my ward round, trying to ignore the stench of urine, vomit and faeces that lingered in the air. One of my first patients had been admitted overnight and I was reviewing her for the first time. She was 13 years of age and had been admitted with presumed meningitis. After reading her notes, I went to examine her. No pulse, no respirations and pupils fixed and dilated. Diagnosis: dead. Let me tell you, this has happened before and it’s not a pleasant way to start the day. She was 13, but already looked like she had advanced HIV. You may ask, “How does a 13 year old get HIV?” The sad answer is that many young girls are often sexually abused when they are little and by the time they reach adolescence, they have full-blown AIDS. I’m not sure how common it is here, but certainly in South Africa, there is a belief amongst a small group of people that having sex with a virgin will cure you of your HIV. This puts many young girls at risk and further perpetuates the cycle of HIV. We see a lot of young girls here who have been sexually abused. Thankfully, I have been shielded from having to actually care for them and for that I am grateful. It would destroy what little is left of my spirit.
I then had to see a twenty year old female with advanced HIV and a pneumonia called PCP. I thought I was succeeding in her management, but today she was confused, disoriented and having visual hallucinations. This happens quite frequently here and usually leaves me with a sinking feeling of impending doom. I wrote up some drugs for her and moved onto my next patient. Meanwhile, she falls out of bed trying to reach for something that doesn’t actually exist, and she starts crawling around on the cold cement floor. She was then sliding in between my feet, guided by her visual hallucination but also showing a look of shear horror and fear like she was possessed. I looked at my nurse and said “you better go and get some help”. I tried to comfort the patient and reassure her that she was safe. My nurse was taking an inordinate amount of time trying to find some help but she eventually returned with two of the male student nurses. With a difficulty that was painful to watch, they hoisted the patient back into bed and proceeded to tie her hands and feet to the railings using scraps of fabric. These are the physical restraints that are used here to deal with “difficult patients” and it really disturbs me to see these very frightened, sick people tied down. She started fighting against the restraints and I ended up ordering a drug to try and tranquilise her so that the nurses could manage her. There simply aren’t enough resources for nurses to do one to one nursing here and this was my only “safe” alternative for the patient. I dread to think what will happen to her over the weekend when I am not around. This is another dilemma I face- for two days I feel like I am “abandoning” my patients and there have been times where I have considered dropping in on a few occasions to check on them. I started doing this when I first arrived but I have restrained myself from doing so lately as I simply need to protect myself from burnout and have two days a week where I am not confronted by death and devastation.
I then went to outpatients, where I was the only doctor present. I started seeing copious amounts of patients, most of whom were co-infected with HIV and TB. Their management is incredibly difficult and I found my headache getting progressively worse. By lunchtime, I hit the wall and I went back to my flat and collapsed on my bed. I ended up falling asleep and I missed the afternoon in outpatients. I felt bad, but I was so exhausted and hopefully, now that the PM had left, the other doctors had returned to work.

So now I am at the beginning of a weekend and I hope it will be a pleasant one.

I am starting to get very nervous about the upcoming US election. Although I am not American, I do follow American politics closely and I am a huge fan of Barack Obama. In fact, I think I love him. This week, I even had a dream about him. It probably was influenced by the fact that I am reading his book “The Audacity of Hope” and the election is so near. We, as volunteers have been very concerned about how we are going to watch the election coverage. We lost our TV so we no longer have access to CNN. We were brainstorming all week and I finally got the courage to ask Dr Wahabi (gynaecologist from Ethiopia) if we could use his TV during the election. He happily obliged and we now have plans for Chris, myself, Susan and my Peace Corp friends to spend Wednesday morning (Tuesday evening American time) watching the election coverage. Kristin and Andrew have even volunteered to make pancakes so that we can make a party out of the occasion. However, let me warn you now, if Barack loses, I’m afraid there will be more tears……
Just so you can appreciate just how far reaching the results of the election are, the other day, I had one of the grounds men here at Good Shepherd approach me and ask if I could do him a favour. He wanted me to try and email Obama and let him know that the Swazi’s love him and they hope he isn’t taking the insults that McCain throws at him personally. I couldn’t help but smile. I had to inform him that although the internet was a powerful tool, I didn’t have Obama’s email address and I wasn’t sure how to contact him. The grounds man was most disappointed.

It was Chris’s birthday this week and we went all out to make it a special time for her. She had two parties. The first one was on Tuesday. I made minestrone and Kristin made a cake. Minestrone is my signature dish here in Swaziland. It is the only thing I can make that reliably turns out well enough for group consumption. Kristin’s signature dish is dahl and Chris’s dish is Cincinatti chilli which is chilli beef made with chocolate and cinnamon and served over spaghetti…….Julia makes her own bread and is just a magician at whipping up cakes that delight us all. Chris then had a second party on Thursday night where we invited all the doctors and their wives over for dessert. It was a nice occasion. Birthdays here are important. The average life expectancy here in Swaziland is 33 (yes, you read that right THIRTY THREE), so any birthday after that age is considered extra special. I hope Chris felt special because she certainly is the ray of sunshine here during the dark times in Swaziland.

Peace from the Peace Corp

2008-10-26T08:01:00.000-07:00

Last week, during one of my darker moments, Kristin and Andrew from the Peace Corp suggested that I come and stay with them for the weekend. I politely declined initially and then I realised that they were living out in a Swazi village for two years- the least I could do was spend one weekend with them.

They came and picked me up from the hospital on Saturday. As part of the Peace Corp, they are not allowed to have their own vehicle so everything is done on foot. We set out for the 40 minute walk along a dusty dirt road with dark storm clouds looming overhead.
Thankfully, it only rained for a short part of the journey and it didn’t distract me from marvelling at all the local people, their houses (made literally of sticks and stones) and the abundance of cattle, goats and chickens that meander alongside you.

We arrived at the homestead that Kristin and Andrew are living in. They are actually living in quite a “flash” abode with concrete walls and a corrugated iron roof that is firmly attached to the base and doesn’t need stones thrown on top of it to keep it in place.
They don’t have electricity and they don’t have running water, but surprisingly, their home is incredibly comfortable and welcoming. They have a gas bottle that fuels their stove and oven and they have purchased some cupboards, a couch and a double bed. Kristin has done a beautiful job in decorating the place and my little flat (which I boast is the best at Good Shepherd) somewhat pales in comparison.
Of most interest to me was the dreaded latrine. I have obviously heard about these amenities and having Noah found in one made me extra curious. Let me tell you- I was horrified. Hopefully Courtney will be able to upload the photos for me, but as you can see the “toilet” is a concrete cylindrical mass that stands to the height of my mid-thigh and it terminates in a pit that is progressively filling with urine and faeces. The stench is overwhelming. You can see that modesty is achieved with some corrugated iron with the sole of a thong used as a lever to open it with. I did use this “toilet” on one occasion but then I refused to use it thereafter- choosing instead to squat behind the building and quickly pass urine. The reason for me choosing to avoid the latrine is that during the night, one of the other members of the homestead had an episode of “explosive” diarrhoea and faeces were covering the entire concrete structure. The structure stands too high so that you can’t just “squat” and I simply couldn’t bring myself to wipe the faecal matter away. Unfortunately, overnight, Kristin also developed an upset stomach and we were faced with a difficult dilemma. I managed to convince her that she simply couldn’t use the latrine, so several times through the day, I went with her to guard against passers-by so that she could relieve herself elsewhere. During the weekend, we brainstormed on alternatives to the latrine (which really is the reason I think Kristin was sick) and I think I helped them come up with some ingenious alternatives that will be put in place as from tomorrow.

I don’t want to concentrate on the latrine too much, because honestly, the weekend was one of the highlights of my Swazi experience thus far. Kristin and Andrew are two of the most amazing people I have ever had the privilege of meeting. They embody the concept of humanity and their kindness, courage and commitment to their calling inspires me every time I am graced by their presence. They are also very funny, very knowledgeable and have a true understanding of both our modern world and the third world we find ourselves living in. We talked for hours and hours and we laughed. I even had the return of my sense of humour that I have lost over the past couple of weeks. I felt so comfortable with them- as though I had known them all my life. They made me feel incredibly special as I was their “first visitor to their home” since they arrived in Swaziland. We stayed up late talking (10pm in Swaziland is considered very late- most of us are in bed by 8pm because we have run out of things to do). They set me up with a roll-out mattress and I was most comfortable. I was a little upset at being woken up at dawn by the roosters announcing the start of the day, but my mood was soon lightened by Andrew making some delicious pancakes and the return of our free-flowing, enjoyable conversation. I feel we know almost everything there is to know about each other. We sat around for hours just talking and laughing. You will be relieved to know that I had the sense not to wear my pink “Winnie the Pooh” pyjamas and I sensibly chose tracksuit pants and a t-shirt. I wore these outside, lounging around inside and then as we walked back to Good Shepherd. It didn’t bother me in the slightest that I had not washed and I looked absolutely dreadful. Here in Africa, that does not matter and the concept is quite liberating for me. That being said, when I got home this afternoon, I jumped in the shower, washed my hair and scrubbed with antibacterial soap. You just can’t teach an old dog new tricks…..
So as I conclude this message, I can assure you that I am feeling much better, reinvigorated and re-inspired to continue my work. Thank you Kristin and Andrew- words will never ever truly be enough to express my appreciation.

Goodbye Noah

2008-10-23T03:24:00.000-07:00

Little Noah died.

I know that he received fabulous medical care, love and attention at the orphange.
I know that everyone there did their best to try and save him.
My heart just hurts so much that I wonder what else could possibly happen in Swaziland that would make me sadder than what I am now.

Thoughts from a crazy shrink

2008-10-21T07:41:00.000-07:00

It’s been an incredibly busy start to the week. My patient numbers continue to explode and I am confronted with difficult, challenging cases on a daily basis.
I’m still struggling with my own emotions. I find myself crying at least once a day. I had dinner with the Pon’s last night and they provided me with a lot of comfort and reassurance. They are incredibly beautiful people who have such strength and faith that it’s hard not to be inspired by being in their company. They have decided that I would benefit from being part of a family for the rest of my stay and they have organised that I will have dinner with them and their children every Monday. I am sure this will help me a great deal.

It seems rather ironic, that in the face of my own emotional crisis, I have been given the rather unwanted role of psychiatrist here at Good Shepherd. I hate psychiatry, almost as much as I hate orthopaedics and I simply detest orthopaedics. However, if anyone seems to show any hint of an emotional disturbance here, it suddenly becomes a “medical” problem and the patient is passed onto me- much like you would pass on a bad smell.

I had a female referred to me from the gynaecologist. She had been admitted with pelvic inflammatory disease (a medical term that softens the real diagnosis of sexually transmitted disease). Anyway, she was behaving in a rather disruptive manner and she was referred to me with the provisional diagnosis of being “psychotic”.
It was with a sinking heart that I went to interview her with my nurse who would act as a translator. Let me tell you, it’s extraordinarily difficult to take a psychiatric history from someone who does not speak English. It is near to impossible when you have underlying cultural differences that make it difficult to determine whether something can be deemed psychotic, or just a little cultural difference that may be considered completely normal here in Swaziland. Anyway, I was able to elucidate that this woman had HIV, she had just lost her job and her husband (who had kindly given her PID) had just run off with another woman. Now I ask my female readers, who wouldn’t be considered a little mad having to experience all of this? Was Lorana Bobbitt ever considered psychotic? If you ask me, it’s perfectly reasonable to be a little emotional having to deal with all of this. Obviously, my opinion does not count here in Swaziland (yet people continue to ask for it). My prescription of an antidepressant to try and help her sleep at night was not considered adequate psychiatric help and I was forced to refer her to Swazilands only psychiatric service in Manzini. I wonder what the psychiatrist there thought when he received a letter with the opening line- “I’m an Australian medical doctor who does not speak SiSwati and does not yet have an appreciation of cultural norms”…….

My second psychiatric consult was indeed much sadder. It was a 15 year old girl who had taken an unknown quantity of an unknown substance to try and kill herself. Thankfully, she did not suffer any deleterious medical effects, but I was asked to see her to “sort out her emotional state”. I found out that she was hoping to take her life because her family could no longer afford to send her to school and she desperately wanted to continue her education. She saw no hope for her life if she couldn’t receive a decent education. Welcome to life in a third world country. In western countries, we have adolescents who desperately try not to go to school. Kids who have no respect or appreciation for education. It made me sick to the stomach. I knew I couldn’t help this girl. I have already spent a good portion of my money paying for Elsie’s (my housekeeper) daughter to finish school. I simply cannot afford to pay for another girl. Instead, I wrapped this girl up in my arms, embraced her as we both cried and then continued on my ward round, trying to alleviate the suffering of a country that is desperately ill.

Sundays in Swaziland

2008-10-19T04:45:00.000-07:00

Noah is not doing well.
After I posted my last blog entry, I checked my email and the people at the orphanage had written to me to tell me that Noah was having cyanotic episodes (ie going blue). This is certainly not a good sign given that he was born prematurely and in a latrine.
I had mentally braced myself for the possibility that Noah has HIV, but I had not braced myself for the possibility that Noah may die before I see him again.

I was very sombre when I returned to my flat. The Pons called to ask me to a braai (BBQ) at their place, but I politely declined. The last thing I felt capable of doing was socialising. I will have dinner with them tomorrow night instead. It’s often difficult for my family and friends to understand, but when I am really upset, I need to be alone. I need time to reflect, I need to reach for my own inner peace. Anyway, Dr Pons then told me that he had spoken to the local Anglican minister in town and mentioned that I was around. Dr Pons asked me if he could pick me up in the morning so that I could attend mass. This was an awfully sweet gesture as Dr Pons does not even attend this church. I think he just thought that I needed some divine intervention in my life.

I don’t normally attend church. As I have mentioned previously, whilst being brought up an Anglican and receiving an excellent education in a Catholic school, I find that my thoughts on God and spirituality do not fit in with these mainstream religions. My spirituality tends to be reflected in nature, the kindness of fellow human beings and the belief that religion is more the way we choose to live our lives rather than the rituals and symbols presented in formalised religion.
Anyway, I decided to accept the invitation and I went along to St Christopher’s this morning. A very small, simple church ministered by a local Swazi called Father Peter. As always, I stood out with my white skin and the recognition that I was the dokatella from Good Shepherd. The people there were incredibly friendly and delighted to have me as part of their congregation. The service was exactly the same as what I have paid witness to in Australia and I am afraid I did not find the enlightenment or comfort I was desperately hoping to seek. Half way during the service, the minister asked me to get up and address the congregation. I was certainly not warned that this would happen, but very little phases me now and I got up to the pulpit. I explained where I was from and what I was doing here and then I started to cry. This is a curse that has afflicted me since childhood. My inability to control my tears in public. I spoke of the burden of HIV in this country and my feelings of helplessness in trying to relieve the suffering. I told them that I had lost my faith. The congregation responded with rapturous applause and I just stood there a little embarrassed at my public display of emotion, but the people obviously appreciated my frank honesty. One of the congregation members then said a prayer on behalf of everyone and she openly and passionately prayed for me. It was really very touching. We then prayed that the recent political turmoil here would resolve peacefully and then we prayed for rain. Water is scarce here and as one parishioner eloquently explained- people are drinking the same water as the cattle.

I then walked back to Good Shepherd. It was 9am and the weather was beautiful. There was almost no one else in sight and the only sounds I could hear were the songs of birds and the occasional groan from the cattle. It is spring here and the Jacaranda trees are in full bloom. It seems like the whole of Swaziland is coated in a carpet of purple blossoms.
It is these moments that give me peace, comfort and a sense of God.

The rest of my day has been spent resting. I am having dinner with the Peace Corp people tonight. Jenny returned to Scotland on Friday and Julia is leaving next week. I know I will feel a deep void when she leaves. We have a new member of our “family”. Her name is Susan. She is originally from Ohio, but a few years ago, she married a British man and she has been living in England for the past 6 years. She is here for 12 months as a public health consultant and she will be working on a project to try and co-ordinate care in those co-infected with HIV and TB. We get along really well and I have spent the week settling her into Good Shepherd. The irony is- I’m now the “local” showing people all around and explaining all the bizarre things here that only a local could ever understand.

A really sh-tty week

2008-10-18T06:25:00.000-07:00

I’ve had another difficult week here in Swaziland. I have cried everyday. It is becoming increasingly difficult to get out of bed each day. I can’t tell if I’m depressed or whether this is a perfectly normal response to what I am seeing here.

My week started badly in that I was inundated with new admissions. I had 12 new admissions to start my week and this is on top of the 20 or so other patients I already had on the ward. The next day, I had a further 10. It’s not like I have another resident to run around and assist me (like at home). I run the whole show and I do everything from all the paper work, all the procedures and all the decision making.
Not only do I see all the medical patients, I am also asked to consult on the gynaecology patients and the surgical patients. They all have HIV and this is considered a “medical” problem, so I am often involved in their care as well. I find it all thoroughly overwhelming. I am exhausted.

The patients are not simple. In fact that are often far more complicated than what I deal with at home. The problem that I face on an everyday basis is that my patients often present to me in an advanced stage of their illness. People are not getting tested for HIV and they often present to hospital with their AIDS defining illness. For those of you who do not understand the difference between HIV and AIDS, I will give you a very brief and simple explanation.

HIV is the virus that causes AIDS. It infects cells of the immune system called CD4 cells. It destroys these cells so that immunity is lowered and the body is then susceptible to catching really serious infections and malignancies. You can assess the progression of the illness by obtaining a CD4 count. Anything less than 200 is considered AIDS because the immune system is so depressed that it is vulnerable to infections that we, with intact immune systems, can usually deal with. We try to start people on Anti-Retroviral (ARVs) Drugs when their CD4 count is 200 or less.

The trouble I face here in Swaziland is that people are presenting to my ward with CD4 counts of around 50, 10 or even 5 (I have had a patient with a CD4 of 3). They basically have no immunity. They present with the most devastating infections such as meningitis (bacterial, fungal, tuberculous), brain infections, pneumonia, diarrhoea, tumours and what is called “wasting syndrome”. If any of you remember the pictures we saw in the 1980s of people who were afflicted by the famine in Ethiopia, then this describes the wasting syndrome perfectly. They don’t just have one illness, they tend to be multiply infected. For instance, I have one patient with a CD4 count of 10. She has what is called HIV encephalopathy which is somewhat like dementia, somewhat like psychosis. She also has PCP pneumonia. She also has pelvic inflammatory disease as well as these horrendous genital ulcers. She also has a raging bacterial conjunctivitis. I have another patient who has PCP pneumonia as well as cryptococcal meningitis. Many of my patients have TB- but not just the pulmonary type- they have TB of the abdomen, pleura, pericardium, lymph nodes and even the skin. We are starting to get Multi-Drug Resistant TB which I see as the next impending disaster here in Swaziland.

I have had a patient on my ward here for sometime and I have been fighting on a daily basis to keep her alive. She was 18 and had advanced HIV with a CD4 count of 35 when she first arrived. She also had lymphoma of the tongue- her tongue was huge and it was difficult for her to swallow. I also think she had lymphoma in her gut because she vomited constantly. We do not have any injectable anti-vomiting drugs here, so I was using antihistamines (which can sometimes help with nausea) and a drug called dexamethasone. I tried everything I could to stop that girl vomiting. Everyday, I would see her and see would be lying in her own pool of vomit. She was so incredibly weak and emaciated that she did not have the energy to roll over and vomit. The nurses were changing her linen constantly, but as soon as she was settled in new sheets, she would vomit again. She was in pain, but the only narcotic analgesia I could give her was oral morphine which she would vomit up. She was so wasted that I could feel through to her spine if I palpated her abdomen hard enough. It destroyed me each day to see her just wasting away. She loved orange juice, so I would go and buy her the juice. She would sip it through a straw because her tongue was so huge with tumour that swallowing any other way was next to impossible. She would then vomit it up, but I knew that she just loved the small time that she had the liquid in her mouth.
This patient died alone on Thursday. Her family never came to see her. She was thrown out when her family found out she had HIV. This happens to many of my women here and it is devastating to me. Despite the fact that the official figures state that 43% of the population here has HIV, it is still an incredibly stigmatised disease. I feel that women here tend to be more affected by the stigmatisation than the men. It is easier for a woman to catch HIV compared to a man. Men here can have multiple wives and multiple partners at the same time and this is considered culturally normal. I feel it is one of the reasons that HIV is so rampant here. Women don’t have many options when they are abandoned by their families or their partners. One of the things which poses a particularly big problem for me and my patients is that in order to be on ARVs, you need to have a treatment supporter who will encourage you to take your medicines. My women are too frightened to reveal their HIV status because they fear abandonment, so getting them on ARV treatment is almost impossible. I have been fighting with my colleagues about this issue, but they are just trying to maintain “national guidelines”. I really feel it is ideal to have a treatment supporter, but what happens to my women when there is no one left around them?

Everyday, I feel that more and more of my soul is being destroyed. I feel overwhelming hopelessness. My sadness consumes me at times. I can’t sleep properly, I look dreadful. My eyes have lost their brightness. I feel so upset by what I am witnessing, that my heart physically hurts at times. At times I am angry and bitter. I don’t like feeling this way. This is not who I am, but I fear it is what I am becoming. I fear that my friends won’t like me when I get home, because the very essence of who I was seems to have disappeared. And yet, I keep going, because everyday I think of my patients. Despite the devastation that surrounds me, I am inspired to keep fighting for them. They are the only reason I am able to find the energy to get out of bed.

On Wednesday, at the height of my despair, I decided to walk into town. I have restarted to walk into town because I need the exercise and it helps improve my mood and clear my thoughts. Instead of the Swiss army knife, I now carry a large umbrella as my “weapon of choice”. It is bright pink and it is called “Mary Poppins”. When purchasing this item, I felt like I was being given a sign. Mary Poppins would never let me down. If needed (and I certainly hope I never have to), I could wield it like a baseball bat.
Anyway, I started off into town. My stomach started to make some rumbling sounds and spasms were starting to make me feel uncomfortable. I kept going thinking that this was just my emotions getting a hold of me. About midway into town I was hit with the sudden realisation that I was about to have my first episode of diarrhoea here in Swaziland. I felt absolute panic. Certainly no public toilets on the way to Siteki. I started to think that I may have to go on the side of the road, but I had two prevailing thoughts:
Firstly- Snakes. What if I was to squat and then have my butt bitten by a mumba?
Secondly- I am the most recognisable person here in Siteki. My white skin, dark long hair
and the fact that I work at Good Shepherd makes me recognisable by most people. I don’t speak SiSwati, but I do recognise that I am a “dokatella” and I can hear people talk about me when I walk past. I simply could not be seen squatting on the side of the road.
I started running back to Good Shepherd. I felt that if I could get my “fright and flight” response going, then perhaps I could try and distract my bowels from relieving themselves. My lungs were burning from the intensity of my pace. My butt cheeks were burning from trying to avoid incontinence. I started cursing myself for wearing my $50 pale pink lace French knickers, because I felt that they may soon be destroyed. I cursed myself for not washing the spinach thoroughly the night before, because this may be the cause of my impending doom.
I eventually reach my flat and I can only describe the experience as an atomic bomb going off in my large intestine. It was horrendous. I then went to flush the toilet and I find that the toilet can’t cope with the volume. My heart stopped beating as I saw the toilet water and its contents rise to the top of the bowl. I was filled with horror and then, by some miracle, it all disappeared before spilling over the edge. I fell to the ground in a heap of relief and exhaustion.
I now have to re-write my list of things most feared on my walk into Siteki:
1. Swazi men
2. Goats and Cattle
3. Snakes
4. A repeat episode of explosive diarrhoea.

Back to Bulembu

2008-10-12T10:13:00.000-07:00

OK, so I panicked last week. I was fragile and feeling really vulnerable and after reading a few comments on the blog, I started to think that perhaps the words I write could be used against me and endanger my safety. I’ve just read the book “A Mighty Heart” and this probably planted thoughts in my head that were out of proportion to the reality I live in. I emailed Courtney and told her to restrict access to my blog. I didn’t know who I could trust. Courtney is beyond any doubt the most incredible friend anyone could ever be blessed with and she immediately responded to my fears and adjusted the blog for me.
I now realise I was a little hasty. I have absolutely no political affiliation here in Swaziland. I am simply a humanitarian trying to do my work at a grass roots level. There is no reason for anyone to use my experience here to perpetuate their own political agenda.
Very few people in the world even realise that Swaziland exists. Few people know what it is like to live in Africa and very few of us know the devastating effects HIV/AIDS has on this population. My words are just describing what I see and in no way have any hidden agenda.

It was quite timely that after my most difficult week in Swaziland so far, that I was taken back to Bulembu. As I have said previously, Bulembu is an old deserted mining town that was bought by some philanthropists with the vision to create a self-sustaining town that would safely house orphans. What they are doing there simply defies anything I am able to put into words. It is ingenious. It is inspiring. It gives hope and it is a place that I have fallen in love with.
I was very privileged to be there for the Board meeting. Philanthropists from all over the world were meeting to discuss logistics and future goals for the town and the almighty project that they are undertaking. Most of them were from the USA, but a few were from South Africa and Swaziland. I was overwhelmed to be in the company of such amazing humanitarians. My role in Swaziland seems to pale in comparison to what they are doing. I am trying to fight the problems as I come across them, these people are trying to create a better future.
Whilst they were in meetings all afternoon, I took myself down to the house where the orphans aged 3-4 are cared for. I spent the afternoon playing with them. I took along some colouring-in books and crayons and I lay down on the floor with them simply colouring. It was incredibly therapeutic. Despite the fact that it has been some weeks since I was originally there, the children recognised me and I was greeted with lots of smiles, cuddles and kisses. I then had dinner with the Board members and I had a truly enlightening experience talking with them, getting to know their backgrounds and what drives their passion to help Swaziland. I was giddy with excitement and hope to actually realise that there are people in the world who not only say they care, but actually show they care.
I woke up to the breath taking beauty that is Bulembu. I was then taken with the other Board members to see some of the projects being put in place. Whilst Bulembu has the ultimate goal to raise orphans in a safe, nurturing environment, it also realises that with this concept, you also need to provide infrastructure, jobs and the ability for Swazis to create a self-sustaining environment for themselves.
We visited the new sewage treatment plant- essential for any community. Who would have ever thought that I would be interested in the workings of sewage treatment, but I was fascinated and appreciated just how essential this was to the project. We then visited a school that is being renovated to accommodate over 200 students (Kindergarten to Grade 12). The school will be opening in January and it looks amazing. This is where the orphans will be educated as well as the children of the workers in the community. I then went to see how houses were being renovated. When the mine closed down, hundreds of houses were left behind in various stages of disrepair. These houses need to be renovated to accommodate orphans. It is hoped that 6 orphans of similar ages will be accommodated with one “mother”. The mother will be a Swazi woman especially chosen by Bulembu to care for the children. The work that is being done on these projects is simply mind-blowing. Progress is slow (remember all this is being achieved with donated money and there is no government input).
I then saw where they have established hives so that honey can be locally produced and then sold outside of Bulembu to generate income. I was enlightened as to how bees work and how difficult it can actually be to run efficient hives!
Off we then went to the factory that will be responsible for bottling spring water. There is an abundance of spring water surrounding Bulembu and this natural resource will be used to bottle water and sell. Again, generating jobs for local Swazis and providing income to house the orphans.
My final stop was the old hospital that remains. Whilst the others went back to their meeting, I was given a set of keys and asked to explore what was left of the old hospital. It was quite an adventure for me. The keys allowed me access to some places but not to others. I ended up climbing over fences, trying to see through windows and at times I thought I would break my neck in doing so, but since being in Swaziland I have started taking risks that I normally wouldn’t whilst in Australia! I felt like an international spy! I found an amazing amount of stuff and I know that this discovery of mine will lead to the equipment being used there and in Good Shepherd- we just need to find a way to break in!

The last part of my time in Bulembu was spent at the orphanage that currently looks after 42 babies from birth to 2 years. An absolutely incredible place run by an extraordinary woman called Robyn and her husband Gerry. They are assisted by numerous other staff members who spend their days feeding, burping, changing nappies, bathing and spending time cuddling babies. It is always a hive of activity and simply one of the most delightful places on Earth. I was instantly drawn to their new arrival. A little boy, about 2 weeks old and weighing 2 kilograms. He was found at the bottom of a latrine (yes, you read that correctly- at the bottom of a pit toilet). He was tiny and incredibly sleepy. I suspect he was somewhat premature because his suck is not great. They are waking him every two hours to try and feed him because he is incredibly weak. I sat with him for 3 hours and during this time I tried to feed him. I am grateful for my time spent in Special Care Nursery back home, because the nurses there taught me how to encourage babies who don’t feed well. I managed to feed him and I was completely besotted. A man, who has never met before, walked up to me and told me that I looked like a complete natural, as though this baby was my actual own. I felt a deep, mystical connection to this child which is unexplainable. Anyway, I had to leave because my ride back to Siteki was about to leave. Robyn approached me and said “this child has not yet been named Melanie and I would like you to name him”
I was simply overwhelmed but I knew immediately that I wanted to call this boy “Noah”. This is perhaps the only child I will ever be able to name and I cried my eyes out as I left. Since leaving Bulembu I have thought about him every minute and I can’t wait to get back there to see him.
Emotions have surfaced that I am finding difficult to deal with. I am 30. Men are simply not interested in me and I realised not so long ago, that my chances of getting married are very slim. Whilst this does not cause me great anguish in itself, the fact that I may travel this life without a child causes me a great deal of grief. It is a thought that I struggle with constantly. (As my step-father Graeme keeps telling me- “My eggs are rotting”) I have always considered adoption, but as a single person, who lives in Australia, this is almost impossible. It breaks my heart that I cannot take a child who was dumped in a latrine and provide him with the enormous amount of love and a future that I am perfectly capable of giving him.
I will now return to my little flat, read a book and try to renew my spirit so that I can face another week of challenges here in Swaziland.

A note of clarification

2008-10-09T01:49:00.000-07:00

I woke up suddenly at 1am this morning and I was filled with dread that I had perhaps said things on the blog that I shouldn’t have made public. The truth is, when I created the blog I only thought 3 people would read it- my Mum, my step Dad and my best friend Courtney. I had no idea that others would read it, I didn’t think that my adventures here in Swaziland would interest anyone else. It certainly never occurred to me that people here in Swaziland would ever stumble across my blog and make a connection with me.

At 1am I felt so disturbed that I wanted to get out of bed and clarify my previous blog entry with you all. I didn’t do this for two reasons:
It’s now cold again and I wasn’t brave enough to leave my warm, comfortable bed.
If I was caught by the security guards that patrol the grounds, they may have been so startled by my wild “bed hair” and pink Winnie the Pooh pyjamas, that they may have shot me- mistaking me for a wandering lunatic.

So I am now here, trying to clarify a few things. First and foremost, the events of Monday are in no way a reflection on the Good Shepherd hospital or its doctors. The hospital is regarded as one of the best in Swaziland. People think the care here is of such a high standard that they travel across the country to be seen by the staff here.
Secondly, the doctors here are doing their best. They are devoted and hard working and they try their best to make a difference despite the gross lack of resources. The surgeon who performed the tracheostomy was amazing and incredibly brave. He actually approached me this morning and told me how proud he was of me. I was the only one in the hospital who was prepared to step in and intubate the patient if the proverbial shit hit the fan. He told me I had “balls” that he had never witnessed in a female before. I have never been told that I have “balls” and I have decided to interpret it as a compliment.
Thirdly, after discussion with the surgeon, we both agree that this situation was doomed to be a disaster in the first place. The trachea was deviated so much that it was underlying the ® clavicle. We have all learnt much from the experience. The patient is still alive and he is grateful that he can breathe.
My reaction to the events that unfolded was completely “normal for Mel”. I am extremely passionate about my work, my patients and the way I am perceived by my colleagues. I know, that even back in Australia, my colleagues find it a challenge to understand me and why I take things to heart so easily. Believe me, I wish I knew why. It can be incredibly lonely at times when you want to fight for your patient, their dignity and comfort, only to meet resistance along the way.
It is my hope that I can continue to write of my experiences here in Swaziland and not have anyone abuse the trust that I have placed in my readers. I hope that you all understand that my patients are people who deserve compassion and dignity. Whilst some may argue that I am breaking doctor-patient confidentiality, I actually see my blog entries as giving a voice to all those who are unheard. As humanity, I believe we have an obligation to care for other regardless of nationality, religion or creed. I believe that ignorance is the fundamental reason why we do not live in peace. It is my hope that I can enlighten some of you to the daily privileges we in the Western world take for granted. Along the way, I will probably use gruesome detail because this is exactly what I pay witness to on a daily basis. It can be overwhelming and it can be sickening. It can make me feel completely hopeless and desperate. It is by using these emotions that I try find the inner strength to do the best I can and try and make a difference. I share the stories with you because I want you to be aware of the suffering that plagues this country and the fact that the rest of the world lives in blissful ignorance.
Please respect my patients and try to understand my emotions. It would cause me a great deal of suffering and anguish if my stories were to be talked about as some idle gossip or if they were ever submitted to Swazi media. I would stop writing the blog and the people I love would no longer have access to a story that is about me and the country I am trying desperately to support. Please respect my colleagues. Whilst I may not agree with some of the practices that occur here, I respect their commitment, their knowledge and their desire to try and achieve some of the goals that are exactly the same as mine.

The roller coaster continues

2008-10-08T09:55:00.001-07:00

I think one of the most difficult things about being here in Swaziland is the day-to-day fluctuations of my emotions. There are times when I am upbeat, positive and truly feel like I am making a difference and then there are days when I am devastating low and feel completely overwhelmed and hopeless. I had one of those days on Tuesday.

I need to tell you about Monday, so you can understand Tuesday.

On Monday I heard that a patient had arrived with an enormous tumour on the side of his neck. I was quite intrigued (in a morbid-doctor type of way). Never in my wildest dreams could I have imagined what I saw. This young man with HIV had a tumour on the side of his neck the size of a soccer ball. I am not exaggerating. It was so huge that it was compressing his trachea (windpipe) to the other side of his neck. He had a marked stridor (a noise that is made when the trachea is partially obstructed) and he was drooling because he couldn’t swallow his saliva properly because his oesophagus (foodpipe) was also partially obstructed. It was horrifying and we all agreed that he needed an urgent tracheostomy (a surgical airway to keep it open). We do not have anaesthetists here at GSH, but rather we have excellent technicians who are able to do various types of anaesthetics very capably. However, I offered to provide a helping hand if it was needed. I had everything set up for a “difficult airway” and I sat for a little while mentally preparing myself as to what steps I would take if one of my airway manoeuvres failed. Unfortunately, it was not communicated to the technicians that I would be in charge of the anaesthetic and this perhaps was the start of one near disaster.
The surgeon wanted to do the tracheostomy under local anaesthetic. I voiced my concerns about this, but being a foreigner and being female, I think my concerns were dismissed. The two surgeons present kept telling me that if we sedated the patient we would lose his airway. I was convinced that this would not happen and that I could titrate the drugs to just make him somewhat calm. Anyway, they started the procedure regardless of my concerns. I was with the patient at his head- I kept talking to him in soothing tones, gently massaging his head and trying my unique way of trying to comfort patients during distressing procedures. It worked really well for a while, but the surgeons were having difficulty accessing his trachea. The patient started to get agitated and I kept saying “We need to sedate him, he’s not coping and this is all going to go really bad”. I was simply ignored and the technicians wouldn’t give me the drugs. Finally the patient got so frightened that he jumped off the bed, retractors and surgical clamps still hanging from his neck. It was a nightmare. People came from everywhere and held him down whilst the technician, without my knowledge, administered a rapidly acting paralysing agent. I was then told to intubate the patient. I was very frightened and nervous. It all happened so quickly and my initial strategic plans were thrown down the toilet. I thought I could see part of the cords. I asked for a bougie and then slid the tube down. During this time and chaos, I think I slipped. One of the technicians listened to the chest and told me he could here breath sounds. I wasn’t convinced I was in the right place. I ended up yelling at the technician to let me have his stethoscope so I could hear for myself. Anyone who knows me knows that I have never raised my voice before in a clinical situation, so it just goes to show how tense I was. As soon as I listened, I knew the tube was not in the lungs. I wanted to try again, but the surgeons insisted on going for a surgical airway and thankfully they succeeded. I then started yelling at the technicians to give the patients some pain relief and they finally allowed me to administer some pethidine. My medical colleagues will be able to read between the lines of this scenario, but I can tell you, I was completely traumatised. The patient was alive and he had an airway, but I felt like a complete failure. I kept ruminating on what the experience was like for the patient and I was physically sick. I had to take valium which I thankfully have easy access to here.
I didn’t sleep. I woke up the next morning and just wanted to die. I had organised to go in early and do my ward round because I was supposed to be taken into Mbabane to get my well overdue visa extended. I did my ward round and went to the administrators office. She told me that I would not be going to Mbabane as some of the documents were incomplete. I can tell you, I almost had a complete meltdown. The visa is not a life or death issue but it’s important because for 6 weeks I have been asking people to get it organised for me. For 6 weeks they have had my documents and nothing has come to fruition. It was the straw that broke the camels back. Chris was with me and she noticed immediately that I was going to explode. Not only had I been through a nightmarish experience the day before, not slept, but I had also got up early to see my patients before my planned trip to Department of Immigration. She pulled me out of the office and we went outside and I started crying. She immediately said “You can’t work today” and we started to walk into Siteki. I cried all the way. I admitted to the helplessness I was feeling. I told her about a patient I had on the ward who has advanced AIDS and lymphoma of the tongue. I told her that my patient is dying of malnutrition because she can’t eat. I told her that on a daily basis I pay witness to people dying the most tragic, agonising deaths that I can’t do a damn thing about. I told her I wanted to go home and that I simply couldn’t cope anymore. She hugged me and told me that she loved me. She told me that I had to keep remembering all the successes I keep having- the ones I tend to forget when they are overshadowed by all the tragedy. I tried to use the internet in Siteki. I wanted to talk to one of my colleagues in Australia and let him know about the incident that had traumatised me so much. Of course, the internet wasn’t working. Chris and I took a taxi back to Good Shepherd. I told her that I would have a coffee and then meet her in outpatients. I had the coffee, but then I went to bed. I desperately needed to feel safe and comforted and my bed was the only place I felt some semblance of peace. I cried and I cried. My tears soaked the pillow and then I fell asleep. I didn’t make it to OPD. Later in the evening I managed to clean myself up as I promised to go to Jenny’s birthday party. I was extraordinarily low, but I honestly think I put on a “good show” and no one was aware of my fragility. The party was a success and Jenny had a good time.
I woke up this morning with a splitting headache, but a good cup of tea and two types of pain killers got me to the ward. Before I even started working, I was told that I would not be working today as Dr Petros was taking me himself to the Department of Immigration. We drove all the way in only to find that more documents were needed from the hospital- I have to go back next week. I knew this would happen. The silver lining was that I suggested that we stop for a cup of coffee. Dr Petros bought me a fantastic cappuccino and a blueberry muffin. It was all I needed to start feeling human again. So I find myself back at the hospital, still unregistered and still trying to alleviate suffering in a country that seems to have no end to suffering. I will stay, I will be strong and I will come out the other side stronger. I hope.
PS. The patient with the tracheostomy is doing well. Despite the ordeal, he smiled at me and gave me a hug. I wish I had the strength of these people.

Extraordinary people

2008-10-05T09:41:00.000-07:00

I thought I would take this opportunity to tell you about a few remarkable people that I have met recently.

Jenny is a 5th year medical student from Aberdeen, Scotland. She has been with us for 6 weeks and sadly she leaves us next week (but not before we throw her a big Swazi birthday party on Tuesday!) Jenny and I get on famously because we both share a passion for any food that is sweet. It is no exaggeration when I tell you that Jenny consumes large quantities of chocolate and sweets on a daily basis. On a particularly good day, she will also eat cake. Whilst I share her passion, I sadly cannot partake in her daily menu. Her metabolism is AMAZING and she maintains her super-model figure despite the thousands of calories she consumes. She is 22 on Tuesday and I keep telling her that once she reaches the dreaded 30 she will no longer be able to eat like this, otherwise she’ll end up with a butt as big as mine.
Jenny also loves shopping and when we are particularly bored, we will sit and imagine what we would buy if we were back home in our respective Western Countries. Last weekend, Jenny and I went away together and spent a great weekend shopping for local souvenirs and eating good food. I will always look back fondly on that weekend as we drove home, with barely any petrol in the tank and dodging cattle, goats and policemen as we made the treacherous journey home.

Last weekend, I also had the privilege of meeting two friends of Julia’s who were here to visit for a short time.
Emerald is a young girl, with a big heart from Maine in the USA. She went to university with Julia. Emerald has been working in Uganda for a year now. She is working on a project which houses, feeds and educates children who are orphaned by HIV/AIDS. Emerald is gutsy and very brave. Nothing phases her and she works very hard, in a difficult country, to try and bring some decency to lives of these children. Emerald is returning home in January. She is returning to the States via Kenya, Rwanda, Egypt, across the Gaza Strip and into Palistine and Isreal. I think she is crazy and I told her so.

Farrah is a delightful girl from Ireland. She studied gender issues at university and now she works for Non-Government organisations in Uganda trying to ensure that men and women receive equal benefit from these charities. Farrah tells me that in Uganda, women are not only second class citizens, a car is considered more valuable than them. It simply breaks my heart. Farrah has just renewed her contract and will be staying on for her third year in the country.

The girls told me a lot about Uganda. In comparison, they thought Swaziland was incredibly civilised and simply amazing. From what I understand, they live in conditions a lot rougher than I am privileged to be in. Their options for food are a lot more limited and their accommodation not so comfortable. They were overwhelmed by the facilities at Good Shepherd. In Uganda, if you go to hospital, you have to take your own bed linen, your own food and your own relative to care for your daily needs. The floors are not washed daily and there is excretement and vomit everywhere. Patients lie on the floor between beds. Violence is common and if you are caught stealing you can possibly be stoned to death or have your hand amputated. Since hearing their stories, I realise how lucky I am to be in Swaziland. For all its problems, I can assure you that here at Good Shepherd, the patients are cared for and I am not allowed to enter the ward until all the patients are washed and the floors have been cleaned. I am truly grateful.

Later in the week, I met Andrew and Kristen. This married couple, both 25 and from Boston, have come here as part of the Peace Corp.
Andrew was a social worker who worked for the Department of Child Safety and Kristen was a paediatric oncology nurse.
The Peace Corp was established in 1960 by John F Kennedy when he challenged students at the University of Michigan to serve their country in the cause of peace by living and working in developing countries. It has now become an international agency devoted to world peace and friendship. Peace Corp volunteers can work in education, youth outreach, community and business development, agriculture and the environment and health and HIV/AIDS.
Andrew and Kristen are in Swaziland under the umbrella of health and trying to develop a programme to help prevent/ treat or alleviate the suffering of HIV. They are required to stay with a local family and get to know the local community so that they can design a project that best suits the local community. They live with a Swazi family of two adults and 3 adolescent children. They live without electricity (like most people in Swaziland) and they share a communal latrine with the family and a few neighbours. When I say latrine, I mean a pit toilet. This is something I simply could not cope with. They do not have a shower or bathing facilities. They use a bucket and water that they need to retrieve themselves daily. I understand that they have a little gas stove and Andrew is currently trying to look at novel ways of creating a refrigerator that does not require electricity. We cooked them a great meal and we intend to make this a regular occurrence for these extraordinary people. I think they are among some of the most delightful people I have ever met and I know that we are going to become firm friends. They simply embody the concept of humanity. They have given up everything to help this country and unlike myself, who can take a shower everyday and have electricity (most of the time), they are doing it at a grass roots level. I have enormous admiration for these people. They are committed to two years here and they are unable to stay away from their community for even a night. They had to walk for about 40 minutes to reach us here at the Good Shepherd and we offered them a bed because it was late when they were about to leave. They had to decline because it is against the ethos of the Peace Corp for them to stay elsewhere. I asked them if there was any food that they particularly craved and they unanimously said “Italian”. This was an incredibly sign, because basically, that’s all I’m able to cook well. Next Saturday, we plan to put on a big Italian feast for them after we search this country high and low for a few key ingredients!

Mumba madness

2008-10-03T09:23:00.000-07:00

Thursday was my hottest day in Swaziland so far. It was more like what I imagined my time in Africa would be like. So far, it has been extremely cold at times and I have often cursed myself for not bringing warmer clothing. I sat in Outpatients, pouring with sweat and fanning myself with a piece of paper between patients. It was most uncomfortable.

The arrival of the warmer weather has also heralded the arrival of my greatest fear in Swaziland- the Black Mumba.

It was about midday when one of the doctors ran into my consulting room asking me to urgently see a patient who had been bitten by the feared creature. I quietly cursed under my breath (sorry Mum, but yes, I do actually swear) and thought to myself “Why is it that I am always called to see the most unsalvageable patients?”

I went into the emergency room and there was absolute chaos. The patient was lying on the stretcher moaning and groaning and everyone was looking on helplessly as if he was about to die eminently. Thankfully, I have been trained well in emergency medicine and despite the chaos, I was able to think clearly. He was breathing and had a good pulse. I instructed the nurses to get bandages and something to immobilise his arm. His co-workers (at a local school for the deaf) had tied a tourniquet with a plastic bag. Once I had applied the pressure bandage, I removed the tourniquet and performed a much more thorough examination. It was soon evident that despite the large bite on his hand, he had not been envenomated. I was able to instruct the nurses on the vital signs and symptoms they needed to monitor and instructed them when to notify me. After peace had settled upon the emergency room, I went back to OPD.

I was soon called by one of the nurses, the patient was fine. However, the police had arrived and they had the “offender” in the back of their paddy wagon. They insisted that I go and look at their proud capture. I am absolutely terrified of snakes and was extremely reluctant to go and see it, but I thought it might be useful for my own protection to be able to identify the creature. I was first proudly shown the bullet that was used to blow the snakes head off. I politely congratulated the shooter and silently wished that he could escort me into Siteki every time I go in for shopping. He was obviously a good shot. I was then shown the feared creature- sans head. It was terrifying and revolting at the same time. A huge crowd had gathered around to pay witness to the big event and it was obvious that this would be the biggest news to hit Siteki all week.

This event has left me with a perpetual sense of dread. I know that my friend Iain has reminded me that I come from a country that is infamous for its dangerous snakes, but thankfully, I have always lived in the suburbs where the risk of an encounter has always been low.
I am now living in RURAL AFRICA and my little flat just happens to be perched on what is known by the locals as “SNAKE HILL”. Apparently, the hill is densely populated with snakes and encounters with the deadly creatures are common. This is why, when I first arrived, I was warned to always keep my windows closed so that I didn’t get any unwanted visitors. Last night, I got out of bed several times to ensure all the windows were closed.
Chris and Jenny also had a scorpion in their house on Wednesday and I have been told that I need to check my bed before I get in each night and check my shoes before I put my feet in. I truly am terrified.
Just so you don’t think I’m a paranoid lunatic (although I’m close to becoming one…), I had found some information on the dreaded Black mamba that I would like to share with you. Read closely and understand why I feel like I’m risking my life every time I step outside my door….

The Black Mamba (nicknamed The Shadow of Death) (Dendroaspis polylepis) is an elapid snake. They are one of Africas most dangerous and feared snakes.[1] The black mamba is the largest venomous snake in Africa and the second longest venomous snake in the world. Only the King Cobra is longer. Adult black mambas have an average length of 2.5 meters (8.2 ft) and a maximum length of 4.5 meters
The black mamba is reputed to be the fastest moving snake in the world, and has been claimed to move at up to 19.2 km/h (12 mph).
A single bite from a black mamba may inject enough venom to kill 20-40 grown men, easily killing one unless the appropriate anti-venom is administered in time. When cornered, they will readily attack. When in the striking position, the mamba flattens its neck, hisses very loudly and displays its inky black mouth and fangs. It can rear up around one-third of its body from the ground which allows it to reach heights of approximately four feet. Black mambas are diurnal snakes that hunt prey actively during the day. When hunting small animals, the black mamba delivers one or two deadly bites and backs off, waiting for the neurotoxin in its venom to paralyze the prey. When killing a bird, however, the black mamba will cling to its prey, preventing its departure. When warding off a bigger threat or feeling very threatened, the black mamba usually delivers multiple strikes, injecting its potent neuro- and cardiotoxin with each strike, often attacking the body or head, unlike most other snakes. It can strike up to 12 times in a row.
Black mambas are among the most venomous snakes in the world. With a LD50 of 0.25-0.32 mg/kg, the black mamba is 3 times as venomous as the Cape Cobra, 5 times as venomous as the King cobra and about 40 times as venomous as the Gaboon viper. Black mamba venom contains powerful, fast-acting neurotoxins and cardiotoxins, including calciseptine. Its bite delivers about 100-120 mg of venom on average, however it can deliver up to 400 mg of venom; 10 to 15 mg is deadly to a human adult
Depending on the nature of a bite, death can, and has resulted in as little as 15-30 minutes or it may take up to 120-180 minutes.

Oh Happy Day!

2008-09-30T07:31:00.000-07:00

Last Friday was one of the most exciting days ever for me. This in itself is testimony to how little excitement I actually have in my life….
Anyway, I got a message saying that there were three parcels at the Post Office for me. I was busy in outpatients, so I sent my friend Jenny (a Scottish medical student) to the post office on behalf of me. After a few forged signatures and a large amount of money to pay import taxes, she returned with three very large boxes of gloves and face masks.
For those of you who don’t know the story, I will let you know the story behind this momentous occasion.
Earlier in the year, my friends at the Princess Alexandra Hospital got together and donated some gloves and anti-TB face masks for me. I actually had a really difficult time trying to find a cheap way of getting them over here. Eventually, I decided to ship them here via Australia Post. I spent $600 in doing so. I used the money that I had been given for my 30th birthday. (In January, my family organised a surprise B’day party for me and instead of gifts, they asked people to make a donation towards the hospital) and I also used the money that had been collected in the Emergency Department I had been working in.
Anyway, after the drama of my documents taking 4 months to get here, I simply lost all hope of my gloves ever arriving. I was simply overjoyed when I saw these 3 huge boxes filled with 5000 gloves and a couple of hundred face masks.
In Swaziland, if you are particularly happy about something, you do this little dance. I have only done this little dance on two previous occasions and both were when patients tested negative for HIV. I performed this third dance upon the arrival of the gloves. I was just so HAPPY! I ran through the wards telling everyone that the gloves had arrived and my excitement became contagious. The nurses were squealing with delight when they saw the high quality of the gloves. I had gloves in various sizes and we were all so happy that we actually had gloves that fit. As I distributed the gloves throughout the hospital, I felt this overwhelming joy and I know the spirit of the staff members was also lifted. I feel so incredibly blessed that I had this opportunity to provide some much needed medical supplies. Whilst it doesn’t directly impact on patient care, it makes a difference to those of us who work here. About 80-90% of the patients here have HIV. They also have diarrhoea, TB and other infectious disease that put us health workers at risk. It is a huge morale booster to know that for a couple of months we will be protecting ourselves in the best way possible.

A rather large dilemma

2008-09-26T03:50:00.000-07:00

This week has been a pretty good week as a whole. Many positive things have occurred and this has lifted my mood enormously.
Firstly, Dr Kalangara, the doctor who was working in Internal medicine and then went on leave on my second day working here, has come back to work! This has relieved my workload in Outpatients enormously. I now do my ward rounds in the morning and then take an hour or so to do some reading or research about my patients before I go to Outpatients in the afternoon. Although I have managed remarkably well so far, it is just so nice to have the time to look things up and educate myself further on conditions I have not yet encountered in my medical career so far. I now feel that I have a much better understanding of HIV/AIDS, TB and a number of infectious diseases that I have not encountered in Australia. I’m not sure that I will ever use this knowledge again once I return to Australia, but I now feel as though I can talk with some level of expertise on these subjects.
Secondly, I have made some changes on the female ward and the results have been extremely positive. Things are much more organised and the nurses and I are working well as a highly functional team. The improvements to patient care have been remarkable. I have made communication between other teams much more effective and people are starting to realise that actually TALKING to other people and WRITING things down actually improves patient outcomes. I have now organised that I will give the nurses a tutorial every second Friday and they are very excited about this new concept. The nurses are taught how to make beds, wash patients, take vital signs and administer medication, but they don’t have a great deal of knowledge about the diseases they are seeing. I can see patient care improving if the nurses understand what they are treating. We will see how things go.
The other big highlight to the week was the instillation of TV in the student accommodation. For the past 6 weeks, I have not seen any TV or heard any radio and I have felt very “cut off” from the rest of the world. Having a TV has changed all of that. For three nights this week, I have met up with Chris, Julia and a Scottish medical student called Jenny and we have sat in front of that TV absolutely mesmerised. We watched the “Red Carpet Special” of the American Emmy awards and we sat for hours commenting on all the dresses and outfits of various celebrities. It was all so far removed from the reality that we pay witness to here, but it was great escapism. The next night we watched “Pride and Prejudice” starring Kyra Knightley and it was simply one of the most enjoyable experiences. I love Jane Austen and despite reading most of her books, I have never seen the TV or movie adaptations. I loved every second and the girls and I squealed with delight when Elizabeth and Mr Darcy suddenly declared their love for each other! It’s the very simple things here in Swaziland that elicits the most excitement!
The only downside to the week was a walk that I took yesterday. Last week, I was walking into town when a man called across the street “I think you have a beautiful bum”
I was absolutely mortified. Although I think it was intended as a compliment, I immediately interpreted it as an insinuation that my backside was rather prominent. Swazi men love big backsides on women and I was so upset that my backside had reached a proportion where it was noticeable. My diet here has changed remarkably in that it is predominantly carbohydrate based and this has led to a gain of weight. I decided that I needed to start an exercise regime as it would be most embarrassing to return from Africa, where people are starving, having put on weight.
The only “safe” walk I can take is into town. Although I have voiced my concerns about snakes, goats and cattle, the honest truth is that my biggest risk here in Swaziland is actually Swazi men. I cannot go anywhere where I will be alone. I was carrying a knife with me (My friend Louise gave me a swiss army knife before I came here and although I am sure she didn’t intend for it to be used as a weapon, I noticed that the knife on it had the potential to inflict some considerable harm), but one of the other doctors warned me that a man could overpower me and use it as a weapon against me.. I no longer carry the knife. Instead, my colleague suggested that I carry something of value on me, so that in the event that I was accosted, I could use it as a bribe in exchange for my safety.
I have nothing here of any real value, so I carry 100 rand (~$18). Hopefully, I’m worth that much…
Anyway, to get to my original point, I went walking yesterday afternoon. I walked past a car wash and a Swazi man grabbed my hand and started pulling me towards a building. I started to pull away and I kept yelling “Let me go! Let me go!”. I eventually broke free and he started laughing at me. He really enjoyed the fact that he had given me a fright. Rather than being upset, I was really angry. My attempt at reducing my butt size had been jeopardised and I felt angry that I no longer felt safe walking into town. I’m really not sure that anything bad would have happened to me as I saw another man walking on the other side of the street, but I can’t be sure.
Either I am going to have to find a walking companion or I’m going to return to Australia with a fat arse.

Culture and confusion

2008-09-24T03:11:00.000-07:00

Over the past 6 weeks, I have tried to tell you of some of the many challenges I face here in Swaziland.
One of those challenges has been trying to understand the culture which is unlike anything I have witnessed in Australia.
I try to speak a little bit of SiSwati. I can greet people and ask them how they are feeling. The people here understand me and they then start rambling on in SiSwati and I have to stop them because I don’t understand any further! I also know a few clinical words. Most of my communication is through an interpreter or through “sign language” for which I have become quite infamous for around here.
The actual cultural background of my patients is a whole new area that I struggle with on a daily basis. My holistic approach to patient care means that I try to find out their background and formulate a management plan around it. A simply impossible task at times.
I will give you an example of one of my most recent challenges.
I had a young girl on my ward who was in her third trimester of pregnancy. She had AIDS and she was admitted onto my ward with meningitis. Initially, she responded well to the antibiotics but then she deteriorated markedly. I finished my ward round on Monday knowing that I would not see her the following day.
I went to outpatients and started seeing some of the hundreds of patients waiting. The situation was simply chaotic. I was trying to see patients there and the nurses in the emergency room were asking me to see patients there and I was being pulled in all directions. I was visibly stressed out.
Then one of the nurses from the ward arrived. She informed me that my pregnant patient with meningitis had just died. She then proceeded to tell me that the relatives were asking what I was going to do with the unborn baby. I looked at the nurse and said to her with some incredulity “Did you tell the relatives that the baby has also died too? A baby cannot be alive in a dead mother”
The nurse told me that they understood the baby was dead but they were wanting to know if I was going to remove the baby. By this stage I was really frustrated and confused and in an exasperated tone I said “Tell the family that I do not remove dead babies from dead mothers!”
If I hadn’t been so stressed out, I probably would have dealt with the situation in a more sensitive manner, but by this stage I was at my “melting point”. I went home that night and felt dreadful about what had transpired.
I went to the nurse the next morning and apologised for not handling the situation more appropriately. I explained that I honestly had no idea what she was talking about.
She then went on to tell me that it is Swazi culture not to bury unborn babies with their mothers. They need to be buried separately. I simply had no idea about this, but the nurse reassured me that this is not a subject that is openly spoken about. It is one of Swazi’s “taboo” subjects and the family probably would not have felt comfortable talking to me about it anyway. Apparently, the mortician removes the baby at the funeral home and the two bodies are then buried separately. I guess in some cases, this is done by doctors. I can assure you, this procedure will not be performed by this doctor.
Despite any misgivings I may have about this, it is something that I just need to accept and hopefully next time will be a little more sensitive about. Everyday I learn something new about Swaziland but I also learn something about myself.

Gospel, God and Going crazy

2008-09-21T06:11:00.000-07:00

I’ve done some pretty crazy things since arriving in Swaziland, but deciding to go into town, in the pouring rain, was perhaps the craziest of them all.
I needed to buy some water and all morning I waited and waited for the rain to stop. By afternoon, I realised that the rain and the blistering cold had set in. I decided to catch a combi into town. You have to feel particularly brave to catch a combi- they are little dilapidated mini vans which the locals use. They are always over packed- for example, if the seat is supposed to seat two, then four sit on the seat. I’m really surprised I haven’t caught TB yet because you are literally sitting on people who are hacking up sputum and spluttering saliva. However, it was my only option for getting water, so I waited outside the hospital for one to arrive.
There were a group of young people also waiting and they kindly offered me to wait under their umbrella. I estimate that the group was in their late adolescence, maybe early 20s. The combi took a long time to arrive. It was so bitterly cold- the wind was cutting through me like a knife and I was getting wet despite the umbrella. However, despite the difficult circumstances, the group started to sing. This leads me to a topic that I have not yet discussed previously in the blog.
SWAZIS SING ALL THE TIME. It does not matter what time it is or what is happening- they sing. Some of them are particularly good and this group at the bus stop harmonised in a way that was truly mesmerising. They tend to also stomp their feet to set the rhythm for everyone else to follow. This particular group was singing gospel and despite the fact that it was in SiSwati, I think they were singing about Jonah.
Christianity is truly alive and well in Swaziland. There are churches of every Christian denomination here and the people are devoutly religious. The only songs I hear are gospel. I wake up every morning to gospel songs. At lunchtime, when I return to my flat to eat, I hear the other staff members in the chapel singing gospel. On the weekends, gospel songs are heard over loud speakers for the patients to enjoy. The nurses often sing gospel songs to themselves as they are working (much the same way in which I would hum a song from Delta Goodrem or Kylie). I often see groups of girls and boys walking into town, singing gospel as they travel along the dusty roads.
A few times a week, a group of women from a nearby church come to sing gospel to my patients on the ward. I have to exert a certain tolerance of this because I am usually still doing my wards rounds and it is hard to concentrate when a group of passionate singers are singing the virtues of God.
Preachers tend to have free reign on the wards. They do not preach quietly. They remind me of American evangelists- they are loud, they are flamboyant and they speak with fervour and passion. I don’t understand what they are saying, but one day I asked the nurses and they told me that the preacher was telling the patients that God would cure them of their illness.
Doctors here often pray before they start operating or seeing patients. One of the surgeons here wears a baseball cap that reads “I love Jesus”. A few weeks ago, one of the nurses was lamenting that she had lost her “prayer partner”- another nurse suggested that she ask Dr Melanie to step into this position, but I wryly replied “I would not make a good prayer partner”. Maybe it was the way I said it, but they erupted in a fit of giggles. So many people have embraced me and asked God to bless me that I sometimes wonder if I am now able to walk on water.
I guess this is what I struggle with most. I was baptised in the Anglican church but I have to admit that I cannot remember the last time I attended church. Mum sent us to Sunday school as children and she then spent thousands of dollars educating my sister and I in Catholic secondary schools. A lot of people presume that I am religious given the way I have chosen to live my life, but I have to admit, I struggle with the concept of God. I don’t know if there is a God and certainly, since arriving in Swaziland and paying witness to the devastation here, I have a hard time believing that God exists or truly cares about people. I know this may offend some of you who are reading this, but I always promised myself that I would be nothing but honest with what I wrote on these pages.
Despite my uncertainty surrounding “God”, I do believe I am a spiritual person. I have a belief in humanity and rather than praying to God, I actually spend a bit of time praying for humanity. It’s not something I do as a ritual or before I go to bed at night, I just spend time in silence, meditating and reflecting on my hopes for the world and its people. I try to live a good, compassionate life that is honest and committed to the good of others. I’m not sure this has much to do with whether or not I believe in God.
When I first arrived here, I could not understand the unwavering faith of these people. These people often don’t have enough money to eat or drink and they are struck down with one of the most devastating epidemics to afflict mankind. I found it difficult to comprehend that they would think that God loves them. Now, after a few weeks of silent observation, I realise that God is all they have. If they find comfort and peace in His existence then I should do everything I can to support this. I wish I could find that inner peace and devotion to help me get through this experience here. I wish Gospel songs didn’t give me a headache.

A roller coaster of emotions

2008-09-19T11:41:00.000-07:00

It seems that I ride a roller coaster of emotions here in Swaziland.
I started the week positive, upbeat and full of hope. By the middle of the week, I came crashing down.
I woke up on Wednesday with a terrible headache- almost identical to the one I had suffered a week earlier. This time, it was bad enough to keep me in bed and prevent me from doing my ward round. I felt really bad. I knew I was letting my patients down- this did not improve the wave of depression that I also thought was starting to envelope me. I spent the whole day in bed- only rising to make some toast and some of that ghastly coffee I continue to suffer.
I got up at 6pm feeling exceedingly low. I managed to have a shower and thought that this was my major achievement for the day. I decided to come to the computer and see if there were any much needed messages. I emailed my Mum and told her I was not doing well. I then emailed my friend Iain and told him that I was “struggling”- a gross under-representation of what I was truly feeling. I contacted him through “Facebook”- quite an amazing achievement given that I cannot even access “Hotmail” from this computer. I remember staring at the screen and it was quite a surreal experience. I was looking at some wacky things posted on his “wall” and I felt so removed from the world I was living in. The truth is, I sometimes feel like I’m living on another planet- things here seem a world away from my existence in Australia. The reality is that I’m only a 15 hour flight away from Australia, but here I face conditions I never imagined existed. I am on the same planet and yet seem so far away.
I was if, by divine providence, that Julia came up to use the computer. She found me just staring at the computer screen. With out any words, she embraced me and it was then, for my first time in Swaziland, that I started to cry. I don’t mean a tiny little sniffle- I mean absolute sobbing, where the pain seems to rise from the bottom of your stomach. I wailed in much the same way as those girls did when they lost their mother. My eyes swelled up and snot poured uncontrollably from my nose. I cried and I cried and I cried. I am grateful that it was only Julia who paid witness to this fragile moment in my life. I know that even though I am disclosing this moment to you now, she will never reveal to anyone else what took place that night. We didn’t exchange any words. There are no words to say in such situations and it is only those that are present who truly understand the extent of emotions that are evoked here.
I went back to my flat, took some of my precious “mersyndol” and slept for another 10 hours.
I woke the next morning and contemplated another day in bed. I felt completely defeated. I then realised that I couldn’t continue like this. I had two options- soldier on or get on a plane and come home. I realised that I probably would never forgive myself if I came home early and I got out of bed and prepared for another day at the Good Shepherd.
The day didn’t exactly get off to a good start. One of the first patients that I went to see looked awfully peaceful as I started to read the admission notes from the night before. I then went to examine her and found that she was not breathing and had no pulse. Lord knows how long she had been dead. She came in with high sugars secondary to her diabetes- I have no idea how she died.
I was continuing the round when one of my surgical colleagues came up to me to inform me about one of my patients on the ward.
This young girl had been with me for some time. She was 18 and had AIDS. She was initially admitted with diarrhoea which I successfully treated. I discharged her home, but unfortunately, she could not pay the bill as no family members came to collect her. She therefore stayed on the ward. During her time waiting for her family, she caught a nasty pneumonia called PCP, again which, I successfully treated.
Apparently, whilst I was in bed feeling very sorry for myself, she started to have a nose bleed. The nursing staff called the surgeon who apparently ordered some medication. The girl continued to haemorrhage and the nurses were getting worried. They asked my friend Chris, to call the surgeon again. Chris called and told him that he needed to come and see the patient. Apparently he was busy in clinic but eventually came to find the young girl exsanguinating. He took her to theatre, but she bled out and died.
He came up to me on my ward round and told me that this girl had platelets of 11 (platelets are the cells in the blood that help it clot and 11 is an incredibly low number). He had taken a blood test on the girl when she was in theatre.
He told me that if I had taken a blood count earlier, I would have known that the platelets were dangerously low- perhaps I could have transferred her to Mbabane for treatment and she wouldn’t have died.
In my already fragile state, this only resulted in yet another round of tears (but thankfully a little more dignified this time). I really felt as though I had contributed to this girls’ death.
After a prolonged discussion with my beautiful friend Katerina, I realised that perhaps things had been blown out of proportion. Firstly, there was never any indication to do a full blood count on this girl. In Australia and US, it is a very common test, but here in Swaziland- I really have to have a good reason to do it. This girl never displayed any bleeding problems and I had no reason to investigate for platelets. I only order tests if I think it will alter my management. Patients have to pay for every test and medication I prescribe and I have become acutely aware of the consequences of over investigating- people simply can’t afford to eat after a hospital stay.
Secondly, even if I did know her platelet count, there was never anything I could do about it. This patient did not have enough money to be discharged from Good Shepherd. In order to be transferred to Mbabane, you need family to take you and money to pay for it. Both of which this girl did not have.
Thirdly, this girl had AIDS and in reality there probably isn’t much Mbabane could have done either.
I still felt very shaken and I was so disappointed that my colleague spoke to me in this way. I am working so hard. This is really difficult. When I’m not working I’m reading textbooks and trying to learn as much as I can. I am professionally isolated here and it can be incredibly lonely.
I woke up today feeling much better. It’s a public holiday here so that people can vote in a farcical election. Nevertheless, it is an opportunity to remind me just how peaceful Swaziland is. Despite all of its problems, the elections should proceed today without any violence. This cannot be said for very many African countries. I am truly grateful that I chose to work here. I cannot imagine how difficult it would be to work in conditions like mine and have the added concern of violence, rape and torture.
I am spending the day with Katerina and Frank. They are returning to Germany tomorrow and they want to spend their last day in Swaziland with me. I am really touched by this. They are truly remarkable people and I feel so blessed to have met them. I will miss Katerina doing the ward round with me. Despite her being a student, she is incredibly bright and I appreciated bouncing ideas off her and her gentle reminders when I would forget to order prophylaxis. I know that this won’t be the final goodbye for us- we will inevitably meet again. Today we will appreciate the “other side of Africa”- we are off to a game park. Hopefully a little sunshine and fresh air will leave me feeling invigorated- ready to face another week.

At last- some hope

2008-09-15T12:27:00.001-07:00

I have just had the most amazing weekend.
My travelling companions were Katerina, Frank and Michelle.
Katerina is a mature age medical student from Germany. She used to be a nuclear physicist until one day, she was travelling around Australia on a motorbike when she had an accident and hurt her ankle. She was in the middle of the outback, with no doctor for hundreds of kilometres and she suddenly knew what it was like to be sick and injured and not have any medical assistance nearby. She quit her high paying job as a designer of BMW motorcycles and started medical school. She plans to graduate and then work in the third world. I love her to bits and she is a true inspiration for me.
Frank is married to Katerina. He is also a physicist and designs cars for BMW. He wants to identify a project in a third world and work along side Katerina from a more strategic point of view. Very warm, charismatic and incredibly smart without being a nerd.
Michelle is from Australia. She is an opthalmology registrar. During her vacation time, she travels to third world countries and volunteers her time on eye projects. She is only here for a couple of weeks, but we have become firm friends.
We started out on Saturday morning in our small 2 door car the size of a Holden Barina. It took us about 3 hours, along a very rough dirt road, to reach a place called Bulembo. The drive was extraordinarily scenic and I began to understand why Swaziland is called “the Switzerland of Africa”.
Bulembo is an old deserted mining town. In 2001, it closed it’s mine and it was left as a ghost town. An entrepreneur in Canada, as well as some incredibly clever South Africans decided to reinvent the town with the sole purpose of helping orphans. There are currently 90,000 orphans in Swaziland (this is in a population of 1 million). The number of orphans is expected to increase dramatically by 2020. Swaziland only has enough capability to house 800 orphans in “institutions”, the rest of them are left to survive with other members of the extended family. This is all great in theory, but the trouble is, with almost 50% of the population infected with HIV, the relatives are simply dying off. There is no one to look after these children. Not only are children orphaned, but there are children here who are abused, tortured and neglected. Babies are often found dumped in the bushes (mothers often have no other choice with poverty and starvation their only option). There simply is no where else for these children to go.
Bulembo was created with the thought that a town could be created where Swazis could be self-sustainable and orphans could be cared for. In only two years, these amazing entrepreneurs have established industry that has the potential to grow and allow Swazis to create a future. At the moment they are utilising the natural resources of the area. They have a logging industry for timber, a honey factory and there are plans in place to open a factory which will bottle water to sell to the public. They also have the most amazing Lodge there to accommodate tourists. The scenery is simply breath-taking- it is so green and mountainous. The air is so fresh and flowers blossom everywhere. The Lodge is idyllic with exactly me in mind. I walked into my room and just gasped at how beautiful it was. You can eat in the immaculate gardens, or sit in the lounge next to a gorgeous open fire. The service is excellent and the staff are truly delighted that you are there.
There are a few walks to do around the area. After we arrived, we started to explore. In the distance I could see a white couple with 5 small black children. My inquisitive nature led me up to them and I was delighted to find out that we had bumped into one of the groups of orphans. This was the beginning of a truly magical afternoon. The children, aged 3 and 4 were very affectionate with us and we played with them, held their hands, cuddled with them and enjoyed their company for hours. The “parents” of these children were two South Africans, the same age as my parents with their own adult daughters and grandchildren. They heard about this programme and packed their bags to come and live in Swaziland and care for a group of 5 young children. The children stay with them until they are 5 when they move onto another residence and start school. These two people are simply angels- sent here from heaven to do one of the amazing jobs on earth. These children are happy, they are well fed and they are healthy. Some of them obviously have HIV, but these people make sure their medicine is given each day and ensure regular check-ups with paediatricians. The children are thriving.
I could barely sleep that night- I was so inspired by what I had seen and for the first time since arriving in Swaziland, I started to believe their was hope.
The next morning, at breakfast, I met the CEO of the project. An enigmatic man called Andrew. He is a born and bred Swazi (although white) and his family have been in Swaziland for generations. He is a lawyer with a commerce background. He told me about his vision for Bulembu and the plans to extend the town, the projects and the capability to care for orphans. I told him that if he could get the funding, I would come back here after getting my fellowship and open a hospital for the town. I will be attending the Board meeting in October.
We then went to another home for orphans. This place was established by Robyn and Gerry- a couple who have been living in Swaziland for over ten years and have devoted their lives to helping orphans throughout Swaziland. Again, I have never met such extraordinary people in all my life. We heard about some of the absolutely tragic backgrounds of some of the orphans and it was simply inspiring to hear of the strength of such little children who come from absolutely nothing. Robyn, with the assistance of 19 other women, looks after 43 babies from birth to three years. The place was absolutely amazing- cots, toys, changing tables, nappies, bottles and baths everywhere. Not to mention 43 adorable black little babies who melted my heart immediately. Despite the number of babies- the place was incredibly clean, organised and efficient. The children were just delightful and I spent hours cuddling and changing the occasional nappy. The babies wear cloth nappies and the people there were amazed at my clever ability to fold nappies and get a bottom changed in a matter of seconds. The fact is, despite the lack of my own children, I have changed thousands of nappies in my lifetime- I can do it with my eyes closed!
I left that place feeling invigorated with a new passion and direction for my life. I cannot wait to share Bulembu with my parents and sister when they arrive in December.
We got back home late to Siteki and I was again reminded of the grim reality of Swaziland and how far we have to go. My ward round was exhausting and chaotic. I hate Mondays as I always arrive to see how many have died over the weekend and then I receive a whole new group of patients with the same devastating illnesses, just different faces. I never thought that I would ever think a “really good day” is when only one patient dies.
The line for outpatients was never ending and it was agonising churning through them all. The reality is that I face exactly the same scenario tomorrow. Life goes on.

Can you believe I've been here a month?

2008-09-11T08:09:00.000-07:00

I have not been able to make many blog entries this week- simply because I have been exhausted and incapable of doing much except for working and responding to a couple of emails.
It has now been a month since I have arrived in Swaziland and for the first time I have felt somewhat homesick. I miss my family and I miss my friends. I miss my work colleagues. I feel professionally isolated here- a feeling I have been lucky enough to have never experienced before.
I have settled into a routine and certainly my efforts on the female ward are having positive effects. I’m recognising clinical syndromes a lot more quickly and some of my patients have done remarkably well. I’m actually discharging people home well and in a much better condition than when they arrived. The nurses really like me and respect me a great deal- the care of the patients has consequently improved immensely. But even so, things here are still incredibly difficult.
Not only am I dealing with predominantly AIDS related illnesses and TB, but I am also faced with chronic problems such as hypertension and diabetes. These are “western problems” and you would think the management for me would be easy. Here in Swaziland- nothing is easy. For instance, I am often having the take into consideration that many of my patients live in extreme poverty. This has numerous consequences
They cannot afford the transport to actually get to the hospital or clinic. The cheapest bus fare (in the back of an overfilled combie bus) costs about 4 rand (70-80cents). Most people don’t even earn this in a day. If I attempt to ask some patients back to review their progress, I’m told that they can’t afford another trip.
They cannot afford the consultation/ hospital fee. A consultation with me costs 15 rand. A hospital stay- much more. They cannot leave hospital unless they have paid their bill. Even if I discharge them, they often lodge in the hospital until a family member can obtain enough money to pay the hospital bill. This leaves them vulnerable to nosocomial (hospital-acquired) infection which is one of the greatest challenges I face in my immunosuppressed patients.
They cannot afford their medications. Many patients come in unwell because they have not been able to afford their diabetic and antihypertensive medication. I have drugs to treat these conditions but my patients are unable to afford them. These diseases are treatable and prevent heart attacks and strokes- the devastating consequences I see frequently.

Everything here is hard. During my ward round today, I got slightly exasperated and said “Is there anything in Swaziland that’s easy?” The nurse who was with me, paused for a moment, thought of her answer and then replied “It’s easy to catch HIV here”. Not exactly the inspiration I was looking for.
I have another patient here. She’s 33 and has AIDS. In 2004 she had a spinal anaesthetic, got an infection and now she’s a paraplegic. There are no services to deal with complicated medical problems like this. She came in septic because of her infected pressure sores. The skin on her buttocks has eroded away and her chronic diarrhoea (another complication of HIV) has embedded faeces into the wounds. I really don’t have any hope for this woman- we don’t even have the facilities to lift here out of bed so that we can clean the areas properly. Incontinence pads here are really expensive so each patient gets one a day- this means that for 24 hours, she sits in her urine and faeces. Antibiotics may help, but the reality is that it will probably be one infection after another. Her CD4 count is slowly deteriorating and I’m even wondering if it’s worth starting her on anti-retrovirals. The thing is, the HIV virus typically mutates and becomes resistant to drugs about every 4 years. In Western countries, we counteract this by prescribing new anti-retroviral (ARV) drugs and I believe there are about 20 to choose from. This allows patients with AIDS to live quite prolonged, good quality lives. Here in Swaziland, we only have 6 antiretroviral drugs, so once resistance develops there are little choices for choosing alternative drugs. In reality, by commencing ARVs, we are not exactly prolonging life for very long. A lot of the patients have compliance issues because they can’t afford to get to clinic for repeat prescriptions. Resistance to these drugs often develops quickly. Many of the AIDS patients also have TB and the two drugs for each illness do not react well with each other- often we have to cease the ARVs so that we can treat the TB. This gives the virus 6 months to mutate and for CD4 counts to decline. I feel like I’m constantly banging my head against a brick wall.
Besides all the clinical problems, there are also many social problems which I don’t feel I will ever be able to influence. Since working on the female wards, I have come to learn that violence against women is very common. I know it’s also common in western countries, but there are very few options for women to leave their husbands despite being continually battered. Women have very little status here and as a consequence there is no framework for women to seek refuge. The low status of women also leads to a lot of sexual abuse, but this is a subject that I have much to say on, so I will leave for a future blog.
It is all a little overwhelming, but today some of my anguish was relieved, if only for a short time. It seems that Swaziland post has finally started working. I sent some documents here in May (I paid $40 to have them couriered here) and today they finally arrived. However, I was also thrilled to hear that I had received other mail. I received my first letter from a friend, Elizabeth, who is a nurse I work with in PA. She is currently in Denmark visiting her son and she sent me the loveliest letter. As soon as I got it, I raced back to my flat, made a cup of the ghastly coffee they have here and savoured every word of the letter. Email is great, but receiving a letter is just so sweet. The other bonus is that the letter was sent from Denmark- home to Australia’s beautiful Princess Mary- a thrill that I think only I could appreciate.
I then got news that I had a parcel at the post office. I was so excited, I just couldn’t wait to go and see what it was. During my lunch break, I desperately tried to find someone to take me into the post office. To cut a very long, complicated story short, I ended up bribing a combie driver to drive me in. The fare is usually 4 rand, but I ended up having to pay him 30 rand. I didn’t care- I was so desperate to get the parcel! The parcel was from my friend Jacqui and she had put together a care parcel- two books, hand cream and lip balm. It was like Christmas day, I was simply overcome. Thank you girls- you cannot imagine what your kindness means to me. No doubt I will read your kind letters for days to come!
I’m going away this weekend- I’m going to visit a new orphanage that has just been set up. No doubt I will give you all the details once I return.

Swaziland makes headlines

2008-09-07T12:04:00.000-07:00

For any of you who are interested in international affairs, I thought you might like to read an article that was in the New York Times. As I have mentioned, I am not a fan of King Mswati III and reading the article, you may understand why.
Go to
www.nytimes.com/2008/09/06/world/africa
Read the article titled "The costs of a living in a fairytale kindom"

The Reed Dance

2008-09-07T11:44:00.000-07:00

The past week was incredibly difficult for me for a number of reasons. I completely forgot to tell you about my experience at the “Reed Dance” last Monday. I got things a bit confused- I thought it was for the King’s 40th birthday, but in fact, those celebrations are today and I am not attending. The Reed Dance is something entirely different. It is an annual event which thousands of young girls participate in each year. When I say thousands, I mean about 60 000. There were girls everywhere! They all have to be unmarried. They all come from various communities and they spend a week preparing for their big dance in front of the King. The reason it is called the Reed Dance is that the girls have to go and cut their own reeds and fashion them into jewellery which they wear around their feet- they obviously make a great amount of sound when the dance.
The girls are transported in on the backs of big lorries- the photo above shows them all arriving. The performance was supposed to start at 12.30pm, but didn’t start until 3pm- THIS IS TYPICAL OF EVERYTHING IN SWAZILAND!

We sat next to all the VIPS- dignitaries from all over Africa. Lots of men in military uniform and lots of men in expensive business suits. Some of their faces were familiar- I’ve probably seen them on the news, but I couldn’t tell you who they were, they just looked important. The Royal family were a short distance away but certainly out of reach of us mere plebs. It was simply amazing- thousands upon thousands of girls dancing around a field the size of two football stadiums. It was colourful, it was vibrant and it was loud.

It seems that the performance also brought the cold weather and I spent the whole time absolutely frozen. It was bitterly cold and as the performance went on and on and on, I started to get very restless- then I thought about all those young girls who were wearing next to nothing. If they were bothered with it, they certainly didn’t show it- they were having the time of their life. This is one of the most special moments ever in a Swazi girls life and they embraced the tradition with every bit of their heart and soul. I simply cannot relate the experience to anything I have seen in the Western world. It was so rich in culture and tradition. I felt very privileged to pay witness to it. I have to admit, we didn’t stay for the entire performance- it was getting colder and it was just more and more of the same thing. We all squashed back into the combie and made the treacherous trip back into Siteki in the dark.
My head was simply pounding by the time I got home. I had purposely not drunk much during the day as I knew the toilet facilities would be less than desirable. I was right and although I felt dreadfully unwell, I was relieved that I had kept control of my bladder all day. I didn’t expect to get home so late, so I was really upset to see that it was dark and my washing was still on the line. Whilst this may seem silly to you, I was warned never to leave my washing out whilst it is dark. Apparently, a particular type of insect will choose your clothing to lay eggs in at night. When you put the clothes on later, the warmth of your body will hatch the eggs and the insects will then crawl under your skin and cause a really annoying rash. I knew that those bastards would find my clothes particularly appealing. The solution, I had been told, was to iron everything well because this destroys the eggs. I immediately started ironing but then ran into a particular challenge- what to do about my padded bras. I thought about putting them in the oven, but alas, I don’t have an oven- just a hotplate. I then thought about trying to heat them up in a frypan, but then thought better of that idea. I realised that I was going to have to take a chance and thankfully, no itching yet. I examine my breast everyday for any signs of infestation.
I’m not completely useless when it comes to trying to solve some of life’s challenges here in Africa. Last night, I was rather dismayed to see that my kitchen sink had clogged up and water (and the sour milk that I had poured on my cereal that morning) had collected in the basin. After a recent stay with my friends, Courtney and Scott and their temperamental toilet, I was well educated on the virtues and mechanism of a plunger. For 15 minutes I sat staring at the sink wondering how I could replicate the mechanism of a plunger. It then came to me like some divine intervention. I put on a rubber glove and cupped my palm over the sink hole. Then using my other hand, I used the same motion that I use performing cardiac compressions. The suction of my gloved hand and the compressions worked like a plunger and that damn sink was clear in no time. I can’t check my cars oil and water levels. Nor can I change a tyre, but here in Swaziland, I can unblock a sink…..

A better day

2008-09-04T09:11:00.000-07:00

The baby is still alive. I went to see him today. He still has quite a bit of respiratory distress but is alert and vigorous. This is a good sign. I was so angry last night because I knew that immediate antibiotics and fluid would be life saving- I was right.
I manged to get Mbabane Hospital to accept my patient. This has been recognised as somewhat of a miracle of sorts- Mbabane very rarely accept anyone from here. Dr Petros says that they would have accepted because I have a very "white sounding voice" and they would have accepted her for that reason. I sadly think that he maybe right. The colour of my skin and my ability to articulate myself well seems to have it's advantages around here.
When I think about the patient that died, I know that I did everything humanly possibly for her. I gave her high dose Bactrim and steroids which is exactly what she needed. The reality is that she had AIDS and this disease is far bigger than me.
I don't always tell you of my successes and if I think clearly and rationally, I am having quite a few. I know that I am contributing here at the Good Shepherd. Not only am I treating patients, but I'm also teaching nurses and some of my colleagues. They are lapping up whatever I give them. I am thinking of running a few "seminars" for the nurses as they seem to really enjoy my teaching. There are quite a few medical students here and I know they appreciate me taking time out to explain things to them. It's no wonder I'm exhausted.
I walked into Siteki this afternoon- always a pleasant experience. People stop along the way and always say hello and ask me how I am. One day, this woman ran up to me and asked if she could carry my bags for me. I didn't let her, but we shared a wonderful conversation as we walked back to Good Shepherd together. People are incredibly kind here.
I am also quite popular with the boys- something that has never been the case in Australia. To my absolute surprise they think I'm quite beautiful and wherever I go they will openly tell me this. I get quite embarrassed as I walk along and they will run up to me and tell me how beautiful or pretty I am. I was a little bit cynical at first, thinking that they may want something from me, but they have never asked for anything. Wouldn't it be nice if we could all live in a world where random compliments abound?

A really bad day

2008-09-03T11:55:00.001-07:00

What you may not have realised is that this blog is as much for me as it is for you. I find that putting my thoughts down in print helps me to consolidate my feelings and provides me with some “cheap therapy”. I know that many of you are following my journey and I almost feel like I have someone to talk to every time I make an entry.

Which probably explains why I am sitting here, in my pyjamas, late at night writing to an unknown, yet familiar audience.

I walked into the hospital, in my pink “Winnie the Pooh” pyjamas without any shame. I already offend everyone here by wearing pants (women here are supposed to wear skirts only) so I thought that being caught in my pyjamas would only give them more fodder to gossip about.
The past two days have been horrendous. I didn’t write in my blog yesterday because I was in the grumpiest mood. I was angry about a great deal of things, too many to put in detail and I was incredibly frustrated. Poor Courtney bore the brunt of it, but I guess that’s what best friends are for.

I had a lady admitted under my care yesterday. She was a 40 year old female who had AIDS but was on retroviral therapy. She was one of the managers on Dr Pons’ farm. Her husband died last year from AIDS leaving her with three children who all live on the Pons’ farm. She presented in acute respiratory distress which my colleague on overnight diagnosed as “hysteria” and gave her some valium. When I saw her, I thought she was going to die. She was too sick to have a chest x-ray and after examining her I thought she may have PCP (a nasty pneumonia commonly found in patients with AIDS). I started her on the appropriate treatment. I have to say, I was pretty nervous. This lady was very special to the Pons Family and I wanted to make sure I did my best. I kept going to check on her and she was making progress. I went to see her this morning and she was markedly improved. She was talking in sentences and had managed to eat some breakfast. I was so incredibly relieved. The rest of the day went smoothly and I actually started to feel that I was really contributing to the wellbeing of my patients. This feeling did not last for long. I was in a meeting this afternoon when my nurses came running in telling me that the patient had suddenly deteriorated. I ran down to the ward knowing full well that this was impending doom. There are no facilities here at Good Shepherd to successfully treat emergencies. When I reached the bed I knew she was dead. As I have mentioned previously, this happens very commonly here- there is very rarely a slow deterioration, people tend to die very suddenly. If any of my medical colleagues have any insight as to why this may be happening- please let me know, because this phenomenon continues to cause me great anguish.
Anyway, I went into the corridor and told her 3 adolescent daughters that their mother had died. All hell broke loose. They all fell to the ground, started screaming and almost convulsing. It was pure mayhem and all I could do was sit on the floor trying to console them. People started coming from out of no where and they all started crying too. It was unlike anything I had paid witness to before. I had to make a discrete exit. I was so upset and I knew that there was absolutely nothing I could do to control the situation. I felt sick to the stomach and automatically started questioning my ability. Had I made the right diagnosis? Had I missed something that could have saved this woman’s life? I know in my heart of hearts that I did my best, but the reality is, there are now 3 young girls who are now orphans.
I was walking out of the ward when I was stopped by one of the nurses. A son of a patient had requested to speak with me. He was from Johanessburg and had just arrived to see his mother. His mother was a 65 year old female who arrived here in a coma. I don’t know why she’s in a coma. An educated guess would be that she had a stroke and I was treating her palliatively. I don’t have a CT scanner to look at her brain- come to think of it, the only tests I was able to perform on her were a full blood count, liver and kidney function tests- all of which were normal. The son did not understand how we were not doing anything for his mother. I tried to explain the situation but he was insistent that I get her to be transferred to Johannessburg. This is simply not possible from here. He wanted to put her in his car and drive her there himself, but I explained to him that transporting a patient, in a coma, who is not artificially ventilated, would be very dangerous. We do not have ventilators here so any chance of me actually intubating her would be hopeless- I would have to hand ventilate her all the way to Jo’Burg. I then thought about Mbabane Government hospital. It is out referral hospital. I already knew that the ICU staff were on strike, but I thought I would give it a go. It was 7pm and I was informed that doctors are only present in the hospital until 4pm- call back tomorrow. I know that this patient will probably die over night and I will have to face the son in the morning. I feel his anguish. If it was my mother, I would be hysterical, but this is Swaziland and this is the reality of our existence.
I then was leaving via the outpatients department when I noticed that there was a baby waiting to be seen. Like a moth to a flame, I was immediately drawn to the child. He was 3 weeks old and looked like he was going to die. He was born to a mother with AIDS and she stood there holding him hopelessly. The doctor on call had a look at him and told the mother that her child would probably die. He was going to admit him into hospital. The nurse asked him about an IV line and he said “I do not put IV lines in children, he will have to wait until the morning”. I was simply horrified. I really like this particular doctor, but I was enraged about this situation. I immediately suggested that I try and get a line. Angels must have been watching over me because I got a line in on my first attempt. The baby was able to receive the antibiotics tonight. What many of you may not appreciate is that this baby looked like it was going to die and it needed immediate fluids and antibiotics. I was just incredibly upset at the way things had turned out because I realised that there is simply no hope in this place. We do not even have the ability to do even the most simplest of things. I am incredibly upset and yet I still cannot cry. This just perplexes me because I am a renowned crier. I have no problems wearing my heart on my sleeve, but suddenly, in the most depressing of all circumstances- I am unable to cry. I feel angry, I feel frustrated, I even feel somewhat tormented and yet I cannot cry. Perhaps if I start I will simply get on a plane and come home, but I know I have so much more here left to do. I can only hope that with the light of another day things will seem a bit easier tomorrow.

Photos of Swaziland

2008-09-02T09:35:00.000-07:00

I am very lucky to have a gorgeous friend, Courtney, who not only is very clever with a computer but is also kind enough to update this blog with some photos to share with you. Don't think for a minute that I'm clever enough to do this on my own!
Scroll down to other posts as she has added photos of Julia and Chris.
Thank you Courtney!

Swaziland, a view from Swazi Candles.

Here is my flat. (The satellite dish does not work!)

My living room

My bedroom

Shopping and Safaris

2008-08-31T11:42:00.000-07:00

Wow, this weekend so far has been nothing short of amazing.
Yesterday, the three of us made our way into Manzini. We were all very excited. Julia even told us that it was such a special day that she decided to wear BOTH deodourant and underwear. Manzini is about an hours drive away from here. It is basically on the other side of the country which gives you some idea how small Swaziland it. Our first stop was “Swazi Candles” and I was just so impressed. It had a candle shop (obviously) as well as a market selling African curios (souvenirs) and an amazing little restaurant. We sat and had coffee (the real stuff- not what they sell here in Siteki) and then we ordered lunch. It was just beautiful. I had grilled Mediterranean vegetables with pesto and mozzarella, toasted in pita bread. After what I have been eating for the past 2 weeks, I honestly thought I was in food heaven. We then shared an American brownie which was delicious. We have vowed to visit this place once a month because the food simply enriched our souls.
We then headed to “Pick and Pay”- a large grocery store. The variety of food was overwhelming and I stocked up with enough food to hopefully last me a month. I was almost delirious with choice. I could get anything that I would normally get in Australia and many of the brands were the same as what is on offer in Australia. I also picked myself up a South African edition of the magazine called “Marie Claire”. I was a little hesitant about buying it- with no TV and radio here, I was going to try and stay away from “western frivolity” but when I saw the magazine, I just had to have it. I have to admit there are times when I am so bored here. If I’m not reading a textbook, I’m reading a book and there are times when I am so tired that I just can’t read either- the magazine will allow me to just sit and look at pictures and escape from the reality which lies outside my window.
I also felt enormous guilt about the food that I was buying. Just last week, I started to identify some real classic effects of malnutrition. Don’t get me wrong- I am not a brilliant doctor, but I started to see a few patients with symptoms that I could just not work out and I was almost certain it wasn’t due to AIDS. I started to do a lot of reading but it was only after talking to Julia that the penny finally dropped for me. Some of my medical colleagues will probably think I’m a bit slow for not having picked up on it earlier, but I have been so consumed with learning as much as I can about HIV and TB, that I didn’t start to think about vitamin deficiencies. Julia goes around to many homesteads handing out medication and food. Her group gives out maize- the staple diet here in Swaziland. The World Food Programme (a branch of the WHO) also works from the Good Shepherd and they give AIDS and TB patients 6kg/ month of a soy-maize based mixture. However, WFP are not able to reach everyone and Julia’s group tend to reach out to the more remote homesteads. Julia tells me that the people out there do not have anything else to eat- maize is the only thing they have on offer. They often don’t have any water and this would explain the bizarre urine that my patients sometimes produce. It’s a very dark amber colour and almost as thick as molasses- it’s quite intriguing. Anyway, when I thought about the nutritional content of maize I finally realised that some of my patients are deficient in Vitamin B and Niacin. The syndromes I am seeing are called dry Berri berri and pellagra and after a couple of days of vitamins, my patients are starting to get better. It breaks my heart that people here don’t even have proper nutrition- how are they ever expected to have any resilience against disease?
After by big shopping trip and the purchase of a few cleaning products, I woke up this morning with the intention to try and clean my little flat. I didn’t know how successful I would be because I didn’t know if things were really old or just really dirty. Turns out things were REALLY dirty. I scrubbed that bathroom and was overwhelmed to see the difference. It was like one of those ads on TV where the bathroom is covered with scum and then after one swipe with a particular cleaning product it comes up shining. Well, believe me- it was nothing short of a miracle. I was so excited by my new clean bathroom that I made Julia come and inspect it. She said it was “glistening”. Dear Julia- she must wonder at times what the hell a person like me is doing in Africa (I ask myself the same question every day)
At midday, Chris suddenly decided that she wanted to go out and because we still had the car, we decided to go to Hlane- a game park about half an hour from here. It just blows me away that we are able to suddenly decide to go out and within half an hour we’re doing a safari. First of all, we had a picnic next to a watering hole where we watched a mother warthog and her two babies drink and bathe. There was also an amazing amount of bird life around. There were rhinos within 30 metres of us and an elephant came down and took a bath. We then went on a sunset safari where we were literally metres away from elephants, giraffe, antelope and my all time favourite- lions. We were incredibly lucky to be about 5 metres away from a male, three females and two cubs. It was just magic. I saw all of this on my trip to Kenya and Tanzania in 2005, but it is still magical second time around.
I decided that I was up to driving home. I had been somewhat reluctant, but I am using my four months here to try and instil in mysel a little well needed bravery. The car we hired was a Toyota made in the 1980s and it was a manual drive. I can drive a manual car (although my sister may argue with me on that point), but I much prefer an automatic. One month ago, I would never have thought that I would be driving a manual car along a really bad dirt road, in the dark, dodging impala, but I did it. I know this may not sound like much to some of you, but I was really proud of myself. I drove really well although I was very nervous. I do not want to drive at night here again, but I know if the need arises, I can do it. Watch out world- Mel is getting brave….

My friends- Chris and Julia

2008-08-29T09:33:00.000-07:00

Yet another week has ended at the Good Shepherd. It’s only been two weeks and yet I feel like I have been here all my life. I definitely have a “routine” during the week, but it helps to have a routine when everything else around me is chaotic.
I have stopped having the nightmares. I’m still not sleeping well thanks to mosquitoes and mysterious noises throughout the night. I confided in my friends that I was having nightmares and they identified with me immediately. Julia told me that she had nightmares every night for a month when she first arrived and Christina (Chris) told me that she takes drugs to help her sleep. I guess this is just all part of the experience. At least I know I am not alone.
I thought I would take this opportunity to tell you a bit about my two best friends in Swaziland.

Chris, as mentioned previously, is from Cincinnatti. She is my mothers’ age (very, very young…) and she has worked in Swaziland on three occasions. Back in the States, she works for a programme which visits homeless shelters and provides health care for those who can’t afford it. She has also worked in the prison system and I think this woman has seen a lot in her lifetime.
Chris makes me laugh everyday and it’s not just a giggle. She is so incredibly funny that I often find myself rolling around in my chair, tears streaming down my face and my sides ache the next day because I laugh so much. She is a ray of sunshine in this place. Chris struggles a bit with the walk back from Siteki. She gets a little breathless, so she stops, has a cigarette and continues on her way. I love her for this. I also love the fact that she hugs me everyday. I am a very tactile person and that hug everyday just gives me the strength to carry on.

Julia is a truly beautiful spirit. She is 23 years of age and has just graduated from nursing school. She has been in Swaziland for almost 12 months and she is very much a local. She speaks almost fluent SiSwati and she understands this culture better than anyone else here. She has really helped me a lot in trying to understand some of the crazy things my patients do. She works for the Home Based Care Programme which visits various “homesteads” (communities) and provides them with basic health care and much needed food. She goes into people’s “homes” and she really does pay witness to the good, the bad and the ugly. Her maturity is far beyond anything I have ever witnessed in any other 23 year old. She is incredibly brave and has a compassion that rivals that of Mother Theresa.
Julia is also a little “Bohemian”. She wears a scarf around her head and today I saw her walking through town with a sack of flour balanced on her head. If it wasn’t for her white skin and pixie-style haircut, I’d swear she was Swazi. Julia has really tried to encourage me to embrace life as a Swazi. I’m afraid she is encouraging the wrong person. I don’t have the heart to tell her that she’s talking to someone who is still applying anti-wrinkle eye cream twice a day and still wearing matching underwear. Speaking of underwear, this is one of the suggestions she has made to me. She has suggested that I just “let everything go” and not wear a bra. I have never been one to obsess about my breasts (other than spend extraordinary amounts of money on underwear- but I am the sister of a lingerie designer so I feel that it is a Genetic problem), but since being here I now have a true appreciation of the effects of not wearing a bra. Swazi women have breasts unlike anything I have paid witness to before. I see a lot of breasts because none of my patients wear clothes. There is no such thing as hospital gowns. Anyway, their breasts are nothing short of pendulous. The other day, I was in outpatients with a woman and her baby. Whilst talking to the woman, the baby reached into her blouse, grabbed her breast and swung it to the other side, lay down and held her breast with two hands as if he were holding a bottle. The breast was able to stretch that far! It was one of those many moments where I had to wear an expression on my face that read “Yes, I see this type of thing in Australia all the time” It’s extraordinary what gravity does to these women. It doesn’t matter if they have had a baby or not, they just look different and Julia suggests that this may have a genetic component. Whatever it is, I can assure you that I will not risk this effect by going without a bra. The other day, Julia and I were walking into town when the wind lifted her skirt. She absently said “Gee I’m lucky I decided to wear knickers today”. I’m not even going to go there……

I love these women to bits. I am overwhelmed by their courage, their kindness and their strength. They will see me through the difficult times here in Swazi and I can only hope that I provide them with some sort of comfort too. Chris says that she finds my consultations with patients hilarious. I certainly do have a unique style. Remember, not many of my patients speak English, so everything is said through an interpreter. The other day I had a woman with urinary stress incontinence. She had had 3 babies and now every time she coughs, sneezes or laughs, she has a little leak. I decided to teach her how to do pelvic floor exercises. This is not an easy task when your patient doesn’t speak English. Anyway, without even thinking, I put my hand between my legs and started pulling a face to demonstrate that I was squeezing my muscles in my nether-nether regions. As I said, I do a lot of things without really thinking how ridiculous they must seem. The patient, the interpreter and Chris were hysterical and Chris now refers to me as an expert in Keigel exercises-Swazi style.

I am very excited about my weekend. Chris, Julia and I have hired a car and we are going to drive into Manzini. There is a large supermarket there and we plan to stock up on groceries so that we can have a bit more variety in our diet. We are also going to have lunch at a restaurant called Swazi Candles. The girls assure me that I will love it. I am looking forward to getting away from Siteki for the day.
On Monday, we are going to the King’s 40th birthday. I have decided to go afterall. Everyone is going and I don’t want to be left alone here. Julia really wants to dance with the other women. This will involve her being bare chested. I am going to support her as God-knows what kind of trouble could erupt when a white girl is bare breasted. I know that last November when I got a little intoxicated at an Emergency Medicine conference, I threatened to dance at this festival to increase my chances of marrying the King, but I can assure you, I will remain fully clothed on Monday. Until then- have a good weekend.

Is Mel medically cleared to work in Swaziland?

2008-08-27T08:02:00.000-07:00

Today I woke up to find that during the night I had stripped the sheets off my bed and somehow I had wrapped myself up in the quilt so that I could barely move. I managed to untangle myself and when I looked in the mirror, I didn’t recognise myself. For the first time in my life, I looked haunted. Yesterday was a terrible day and I consequently experienced nightmares throughout the night. I do not usually suffer nightmares. I had four people die in front of me yesterday. One of the patients included my 13 year old, Patience. I knew her death was inevitable, but in the end it was quite gruesome. The three other patients who died yesterday were all younger than 30. I have obviously paid witness to death many times, but nothing on the scale of this. Dying from AIDS is one of the most horrible deaths I have ever seen. Before I left Australia, I knew that I would face this- I thought I was prepared, but the reality is far more than I could have ever imagined. I’m not falling apart, in fact, I haven’t shed a tear. Perhaps this is my problem. Perhaps a cathartic howl would do me good. I had my cup of tea this morning (this is my “drug” of choice at such times), had a shower and managed to face the day as positively as I could. Only one patient died whilst I was doing my ward round. I see this as somewhat of a good day.

Nearly 50% of the population here have HIV. This statistic means that one in every two people have a life-limiting illness. Most will die before they are 40. Imagine if we lived that way in Australia or US. Imagine having this disease and knowing that your country does not have the resources to treat it. Imagine not having enough food or water so that your disease progresses so quickly because you are malnourished. Imagine that you have no job, no income and yet if you want to see a doctor you have to pay money. If your doctor orders a test, you have to pay money. If your doctor prescribes you a treatment, you have to pay money. In fact, so many people here cannot even pay the bus fare to actually get themselves to a doctor. Imagine if you are a doctor and you know that your patient has no money and you know that if you order a test, or even order paracetamol (acetaminophen), your patient somehow has to find the money. It breaks my heart and causes me great anguish.

What has compounded my grief this week is the knowledge of what lies ahead next week. Next week, the King of Swaziland turns 40. This also coincides with Swaziland celebrating 40 years of independence. Huge celebrations are going to take place. In the newspapers, they tell us that 40 Mercedes Benz have been bought to transport officials- one of who is Mugabe from Zimbabwe. The King is also going to take a new wife next week. This will be his 13th. This week, he sent 10 of his wives, their children, the nannies and bodyguards to Dubai on a chartered aeroplane. This is for a holiday and perhaps so he can have some time alone with his new wife. The thought of all this happening whilst I pay witness to what is happening here makes me sick. But this is Africa.
I was planning on going to the celebrations, but I feel as an advocate for my patients, I should not attend. I do not want to be seen to support this. However, escaping this place for a day may actually do me the world of good, so I will see how I feel.

On a lighter note, I thought I would share something that brought a smile to my face. I am going to be registered as a doctor here in Swaziland. I filled out the necessary paperwork and I then had to get a medical certificate signed to “medically clear me”
The certificate read as follows:
I hereby certify that I have examined …… and find that she is not mentally or physically defective in anyway. That she is not an idiot, epileptic, insane, mentally deficient, deaf and dumb, deaf and blind or dumb and blind and that she is not suffering from leprosy, TB or trachoma.

I am not joking, this is exactly what the official document said. I was eventually able to find someone who would sign it for me……

A new volunteer!

2008-08-25T08:36:00.000-07:00

Yesterday, I was delighted to meet a new volunteer who will work at the Good Shepherd until Christmas. Her name is Christina and she is a nurse practitioner from Cinncinatti. Her accent is typical mid-west and she is such a riot! This is her third stint at the Good Shepherd and she certainly knows her way around. She is helping me see patients in Outpatients and I feel that she is like an angel sent from Heaven!
My ward round went for 5 hours today- so many new patients and all of them with devastating disease. I am afraid that my death rate is increasing by the day. Another doctor here told me that I am not alone. He has been working here for 2 years and he says that things are much worse than when he started. AIDS is completley obliterating this country. What surprises me is how quickly they die. They seem to go from being alive and relatively stable to dead within minutes. Today, a family brought a young girl in. Patients often arrive to outpatients in the back of a ute or even in wheel-barrows (yes, you read that right, they are wheeled by their relatives, often for kilometres, in wheelbarrows). This girl had pneumonia diagnosed two weeks ago. Today she became worse, went unconscious and was dead on arrival. Most of my patients die when I am not on the ward, so I have not yet paid witness to how families react to death. Basically they all collapse on the ground, wailing and hysteria breaks loose. It was complete mayhem and I have to admit, I excused myself to come to the computer. I could not pay witness to the pain any longer.
Today, I made another friend. Elsie is a young Swazi woman who is a mother of 5. I have employed her to do my washing each week. I am thrilled that someone is able to do my washing. There are no washing machines here and I was very concerned about the prospect of handwashing all my clothes. Things are difficult enough as it is! Anyway Elsie arrived at my door at 6.30am. I ended up inviting her in for tea and toast. She looked like she could do with a good meal. I think this will become a ritual for us. She seemed to really enjoy the meal and our conversation- in very broken english- was pleasant. She works to give her children an education and it gives me a great sense of satisfaction that what I pay her is going to pay for a child's education. I went to inspect the clothes line at lunchtime and she has done an amazing job- far better than what I could have done.
Tonight, I am having dinner with Julia and Christina. It should be a lot of fun. They are my lifeline here in Swazi. I think these nurses will be my friends for years to come. We are hoping to go away for the weekend soon and I will look forward to that event with much anticipation. Dr Pons, a South African opthalmologist here, wants to send me to a conference in Cape Town. I don't like my chances as I will still be the only doctor in internal medicine, but he says he will have a word with the boss and see what he can do. Keep your fingers crossed!!

More things to worry about...

2008-08-25T08:34:00.000-07:00

It is not all gloom and doom here at the moment and I do have moments where I can escape from everything.
I woke up yesterday morning to the sounds of local Swazi music blaring into my bedroom. My little house is next to the student nurses quarters and they obviously like to spend their Saturday mornings much the same way that western girls do. I always hear lots of laughter eminating from these quarters so I suspect life as a student nurse is good.
Later in the day, Julia and I went into town and onto Maduba Farm. This is a property owned by the hospital’s ophthalmologist. As a side business, they run a Bed and Breakfast and this is where I will be staying with Mum, Graeme and Rachel when they come to see me at Christmas. I needed to go and pay a deposit to ensure our accommodation. Anyway, Julia and I started walking along the road to Siteki.
Let me tell you, I am not always convinced that this is a very safe excursion, but nonetheless, it is my only option at the moment. The cars zoom alongside at speeds way over the limit. My other fears include goats and dogs which amble alongside me. I know that most people consider goats harmless, but my beautiful sister Rachel, has had many an unfortunate experience with goats in her lifetime (one once bucked her into a bush of stinging nettles) and I fear that I will suffer the same fate. They look gentle enough, but I know that under that gentle exterior there is an evil spirit just waiting to buck me into danger. The other concern is dogs. Julia has warned me about them and has told me to be prepared by always carrying rocks with me to throw at them should danger approach me. The only problem is, that if I was to be approached by a threatening dog, my first reaction would probably be that of loss of bladder control. The second problem is that I am dreadfully uncoordinated. Any attempt at me aiming a rock at an approaching dog would be simply laughable. I have thought about carrying a stick with me, but the best I can find is a broom handle and I fear I will be the laughing stock of Siteki. Have I mentioned that rabies is common around here and I chose not to have that one vaccination?…..
Anyway, Julia suggested a “short cut” to Maduba. Given that I trust her with my life, I agreed. It involved traversing open fields and climbing through barb wired fences. It was actually a pleasant walk until we were confronted by a herd of ~ 100 cattle, all who looked pretty pissed at us disturbing them. I suddenly was reminded of my bladder control issues in times of danger. Thankfully, my pelvic floor muscles did not embarrass me. The cattle started mooing and as they approached their horns just seemed to get larger and larger. I held Julia’s hand and she quietly told me to start acting like a black person (a bit hard when all the blood had already drained from my face). We walked slowly and casually and did not make eye contact with the beasts. Thankfully, we made it safely past them and mad it to Maduba Farm in one piece. I will not take that short cut again. However, Julia then proceeded to tell me that she doesn’t like taking the conventional way to Maduba farm as she was mugged and robbed whilst returning from a visit there several months ago. I am now faced with the dilemma- get trodden to death by a cow or mugged by an African?…..

2008-08-25T08:27:00.001-07:00

It has been a rough weekend for me. The reality of what I am facing here suddenly took hold and I have not been my happy, cheery self.
Friday was a rough day. Outpatients just seemed to be a continual stream of difficult patients. I was also managing the patients in ED and my patients in the ward. I was being drawn from every angle. I had an old man present to me because he couldn’t walk because of excruciating back pain. He had to be to outpatients several times with this complaint and had been given analgesia. I started to think that we better investigate the pain further. I ordered an x-ray of his spine and found that he had a crush fracture to L1. The fracture did not look typical and I started to think that perhaps he had TB of the spine. I have never seen this before but only read about it. Trouble is, I do not know what the findings are on x-ray. I consulted the textbook that I have but it was very non-specific. I was getting incredibly frustrated as I had the potential to truly make a difference in this man’s life by making the correct diagnosis. Being a Friday afternoon, there were no other doctors around to ask for advice. As I have said previously- I am the only doctor in internal medicine. I ended up sending the patient away with analgesia. I cannot start a patient on 6 months of TB treatment if I am not sure of the diagnosis. I am going to try and get some help from my colleagues in Australia and hopefully the patient will return at some stage so I can help him further.
On Monday, I admitted a 13 year old girl called Patience. She is exquisitely beautiful, but she came in septic and very unwell. What I have failed to mention previously is that almost all patients present to a “Traditional Healer” (witch doctor) before they present to use. Often the patients are given herbal remedies and often there is cutting of the skin involved (I think this is an attempt to “release the poison” that is making them sick)
Anyway, Patience had multiple cuts to her legs (thanks to the traditional healer) and the leg was badly infected. I did a lumbar puncture on her and the lab reported it as negative, which was of some relief to me. I commenced her on antibiotics and throughout the week, as she has deteriorated, I have tried more and more different types of antibiotics. She is not improving. Her fevers are still above 39 degrees celsius and she is now in a coma. I have examined her many times, increased all her meds and she is getting worse and worse. I have sat by her bedside and racked my brains as to what I can do for her. I know she is going to die. I wish I was smarter. I wish I knew what else to do. For the first time in my life, I feel hopeless.
I am not a brilliant physician. I communicate well with my patients and because of this, I am often able to find out their symptoms etc. If I am unclear of what is going on, I ask someone smarter. I have never been inhibited by my ego. I can admit what I don’t know something. I also have a good relationship with my colleagues and this combination has always led to the best outcomes for my patients. Here, I am alone. I don’t have anyone to ask. I am limited in my knowledge as I am facing diseases I have never seen before. I feel like I am failing my patients. I have never had this feeling before. These people have nothing and I feel that I am letting them down.
In an attempt to remedy this, I have spent the weekend reading. My beautiful friend, Julia, found me a copy of the National guidelines for treating TB. I have devoured every word. We have a TB clinic here and they manage most of the patients here, but they refer to me the difficult cases- quite ironic given that I am the least experienced of the lot of them. Today I will read about HIV.
I saw my patients yesterday despite the fact that it was a Saturday and I am not expected to work. I just had to check on their progress. I performed a lumbar puncture on a lady who presented on Friday afternoon. I had to take the specimen to the security guard who then took it to the house where the lab technician lives. I think I am the only doctor who has called the lab technician in on the weekend, but I will deal with the repercussions on Monday. The positive about this story was that the LP identified a bug called Cryptococcus. This allowed me to give her a drug that I had not prescribed her. I had given her antibiotics against bacteria and this lab result told me that I needed to treat her with an anti-fungal. I was so happy to have a firm diagnosis and to be able to give her the correct treatment. My happiness was then overshadowed by the thought that I will probably have to tell her that she also has AIDS. Success is only momentarily sweet.
I was going to go in today to check on my patients again, but I have decided against it. I need one day where I do not have to pay witness to the devastation and hopelessness of this situation.
Tomorrow is another day.

2008-08-25T08:27:00.000-07:00

My first week at the Good Shepherd

2008-08-21T08:18:00.001-07:00

I was wondering if I would ever be able to post an entry again. The electricity is continually shutting down and this computer is tempramental to the point that I could just throw it out the window, however, like everything in Swaziland, I am going to have to learn some patience- everything here works at a snails pace.
Like I expected, my first few days here have been nothing short of chaotic. I wish I was a better storyteller as the words I am about to write do not truly give a good depiction of what I have encountered.
On my first day, I saw all the male and female medical inpatients and it was enormously overwhelming. From my log book I have worked out that ~90% of the patients have AIDS and they are complicated with diseases that I have only read about. Lots of meningitis. TB is rampant. Have seen typhoid, lots of diarrhoea and AIDS related chest infections such as PCP. Many patients have horrendous oral/facial tumours that just eat away at their flesh. One lady has a perforated palate. We do not have any injectable morphine so my options for analgesia include paracetamol (acetaminophen), ibuprofen and panadeine. I cannot give my patient with the perforated palate any analgesia because she cannot swallow. She obviously can't eat so I expect her to die at any moment.
Yesterday I diagnosed a lady with leukaemia. I made a desperate attempt to transfer her to Mbabane (capital), I went to write a referral letter and the nurses informed me that she had just died. No warning, no acute deterioration- just died. A 30 year old female delivered her first baby, went for a shower and then just died. We will never know why.
The bed situation is a complicated affair. Men and women are separated and they can never mix. We ran out of male beds yesterday and I suggested that we put the men in the vacant female beds- I was met with a look of resounding horror from the nursing staff- it is not "Swazi" to mix the two. When I say that we ran out of male beds, I mean that every bed is occupied, the floor space between the beds is occupied and the area outside the administration offices is occupied. We don't have access block in the ED- if there are no beds, the family have to take the patient home (they are often dying) and return the next day to see if there are any beds available.
The Emergency department consists of 3 archaic trollies in a very small, crowded room. There is virtually no equipment. I do several lumbar punctures a day. I use a piece of cotten wool soaked with betadine and a spinal needle. No sterile gloves. No drapes. No local anaesthetic. For my non-medical friends, I can tell you that this is an extremely primitive and dangerous way of doing this procedure. I do it anyway as a great many patients have meningitis.
Gloves are in really short supply. We do have some gloves that resemble the plastic bags that you put your fruit and vegetables in at the grocery store. They are really big and flimsy. There are some rare latex gloves but they are used for particularly dangerous procedures. Sharps bins are in short supply and this concerns me given the enormous rate of HIV. No one could find one this morning and I was told to leave my spinal needle in a cardboard shoebox to be disposed of later. I have to say, it was the first time this week that I nearly lost it (and there have been plenty of opportunities this week where I could have lost my cool). I ended up taking the needle to men's ward and finding a bin there- an expedition that was frought with danger in itself.
At the moment I am looking after the female ward and then after my rounds, I go to outpatients where I see all the medical patients. I really enjoy looking after the women. I feel that they are at the bottom of the Swazi pecking order and I hope to bring them some dignity and compassion as I look after them. The other doctor who looks after Internal medicine goes on leave today and I now am the official doctor for this department. God help me and all the patients.
I have so much more to write, but I thought I would just start by describing some of the medical things I have encountered this week. I have so much to tell you about all the funny things I encounter outside of my medical work.
I cannot receive email here via my hotmail account. I have no idea why. If you would like to email me- send an email to doctors@realnet.co.sz. Put my name as the subject heading and I will have an easier time accessing the messages.
I will try to post again on the weekend- if the electricity is on and the computer is working!!

I have finally arrived in Siteki

2008-08-17T09:12:00.000-07:00

I didn't think that I would ever get here, but I have finally made it to the Good Shepherd Hospital. I flew to Manzini in a very small aircraft and then arrived at a very small airport. After two hours of waiting very patiently, someone arrived to pick me up. That someone was a nice local man called Promise. These types of names are not unusual around here.
The drive to the hospital took about an hour and I paid witness to very "african images"- cattle and goats that wander on the sides of the road. Children playing in dirt next to the side of the road and women carrying babies on their back and big bags of produce on their heads. Cars, trucks and combi vans packed with people and driving way over the speed limit. Signs on the sides of the road telling the locals to "Trust condoms".....
I was shown to my accomodation. It is very comfortable considering where I am. I have a bed, a flushing toilet, running water and electricity that was on for most of the day. My hair straightner works and this provided me with a great deal of relief.... I also have a fridge and a very small hot plate which will allow me to cook meals. I feel very lucky to be provided with such "luxuries"
I was then fed in the local kitchen. Some chicken and some rice, both of which were coated in oil. Dinner was the same chicken, but fried. Needless to say, I will be doing my own cooking.
I was in my "Winnie the Pooh" pyjamas and washing my face when Dr Petros (the director of the hospital) knocked on my door. I was most embarrassed but he was simply delighted to see me. He kissed my hands and was just beaming that I had finally arrived. I know know why he is so excited- the doctor who normally runs internal medicine is going on leave next week and it looks like they plan to make me run the department. This thought is just crazy and I am terrified. I have no idea how I will cope. I have done a lot of reading today and I am quite overwhelmed by what I may potentially have to deal with.
My other big concern is now snakes. Dr Petros warned me that we are about to enter snake season and he made me close the windows that I had widely opened. I have since learnt that Swaziland has a number of dangerous snakes- the deadly mumba, cobras and puff adders. I am simply terrified. Now along with HIV, malaria and worms, I am now consummed with fears of snakes.
I made the walk into town this morning and went to the supermarket. I was pleasantly surprised by my options. Whilst it certainly isn't like a normal supermarket, I think I will be able to find enough to keep me from starving. I bought cereal and milk. I also bought bread and baked beans and tonight I will cook myself some pasta- there was no pasta sauces but I have bought tomatoes, spinach and mushrooms and hopefully I will be able to make myself something edible. They don't have regular coffee here- just something made with chicory. I have been told that I can get coffee in Manzini, but I have my own supply which will hopefully last me a week or so. I brought my own tea bags from Australia- thankfully, because they only have that revolting rubois tea!
There are no other volunteer doctors here, but I do have a very special friend, Julia. I have been in contact with her for quite a few months and it was just delightful meeting her in person. I have spent quite a few hours with her and we get along famously. She is from New York and has been working here for 10 months. Her knowledge of the local area is amazing and she will definitely look after me. She has learnt the local language and she is trying to teach me- so far, I am hopeless. We will look after each other (actually she will probably look after me...)
Anyway, I keep getting disconnected from the internet, so I will end here. I haven't been able to contact Mum and Graeme via phone, but hopefully, I will sort out a phone sometime this week. Until my next post, please pray that I don't have any encounters with snakes....

Not quite there yet....

2008-08-15T12:57:00.000-07:00

I think today has been the longest day of my life. I was up at 3am to get to the airport by 5am. I have now been awake for 27 hours and unfortunately have only made it to Johannesburg. I was delayed 7 hours in Sydney because there were "engineering problems" with the plane. In other words, there were fumes in the cabin and no one knew where they were coming from.
The time in Sydney was not too bad. Travelling alone seems to make me a magnet for anyone who wants a chat. I spoke with a couple from Zimbabwe- they had been kicked off their farm and it was fascinating hearing first hand how they live under Magabe's regime. I then spoke to another man who lives in Johannesburg and again, it was fascinating to hear how he lives. I then met another couple who live in Jo'Burg but had been in Australia looking at their options to immigrate. They are astounded by the freedom the Australian lifestyle allows- something I think we all take for granted.
I had another brush with fame today. The Australian Wallabies (a rugby union team for my non-aussie friends) were on the flight. I recognised a few faces, but Loti Ticquiri is the only name that I can "drop". I found it somewhat ironic that they were sitting in business class about to be payed thousands of dollars for playing a rugby game, whilst I sat in economy about to be paid nothing for helping the sick....
Arriving at Jo'Burg airport was terrifying- it was pure chaos and I have to admit, it was the first time I had some tears in my eyes. I had no idea what to do as I had obviously missed my connection to Swaziland. I have learnt my first lesson about getting around in Africa- Money talks. I would hold up some cash and ask for directions and suddenly these African men were bending over backwards trying to help me. I am now in a beautiful hotel near the airport and hopefully I will get on a 10am flight to Swaziland. I'm still really buzzing about the whole experience, so I'm going to have a shower and then take my magic pills which will hopefully put me in a deep slumber. I have to admit, I fear what will be in my dreams. My good friend Darren Powrie planted a seed in my mind the other day- he told me I had a good chance of getting worms. He also gave me a textbook on parasites which I started to read whilst on the plane. I was absolutely horrified by what they could potentially do to me- crawling into my skin, spreading to my lungs, liver and then blood stream. Forget malaria and HIV, I'm now more worried about worms. It would be most unglamorous to be diagnosed with worms.
Hopefully my next post will be from Swaziland.

Only one day to go....

2008-08-13T17:46:00.000-07:00

This is my very first entry and I hope that I am able to continue updating you whilst I am in Swaziland.
This time tomorrow, I will be on my way to Johannesburg. I have to be at Brisbane airport by 5am so it's going to be a very early start for Mum, Graeme and myself. My parents insist on taking me to the airport and I suspect it will be quite an emotional scene for all my fellow passengers. I have to fly to Sydney first and then I fly to Jo'Burg. I have a short stay in the airport there before I catch a flight to Manzini in Swaziland. I have to stay a night there as I arrive in the evening and I'm told it's too dangerous to travel on the roads at night. I have no idea what "too dangerous" means... Anyway, someone from the Good Shepherd Hospital will be picking me up the next morning to take me to Siteki. I'm told I'll arrive just in time to have lunch at the hospital. I have no idea what I will get for lunch.... I'm certainly hoping that they don't expect me to start work right away. The director of the hospital has already told me that I'm going to be very busy!
I haven't physically packed my bags yet- this is definitely something I will need help with. I have a lot of stuff. It's all in the study at the moment and I keep taking small glances at it all and praying that it all fits. I think I have done extraordinarily well in deciding what is "essential". I'm only taking 4 pairs of shoes and this is quite an achievement for someone like me. The hair straightner is definitely going despite warnings that I may sacrifice all electricity to the hospital every time I use it.
This week has definitely been a roller-coaster of emotions for me. On Monday I was very upbeat, positive and excited. On Tuesday I started the day by crying my eyes out. Wednesday was a mixture of all emotions and today I have started physically trembling. My stomach is doing flip-flops and my head is just racing with thoughts of what I need to do before I go. I doubt there will be much sleep for me tonight...
Mum bought me a journal the other day with the following written on the front page:
"God grant me the serenity to accept the things I cannot change; courage to change the things I can and the wisdom to know the difference"
It is with this thought that I say goodbye to Brisbane and embark on my adventure in Swaziland.