MABIBI BEACH

Last weekend we caravanned to Mabibi beach on the south eastern shore of South Africa. Turns out that when they say, “you need a four wheel drive”, they weren’t kidding. We had two RAV 4s and one Toyota Corolla. The Corolla got stuck in deep sand approximately 15 times before finally getting stuck so badly that we couldn’t drive forward and had to get help to get pulled out. We then had to back track, park in secure parking and get a ride to the campground from a 4 WD. It turned a 5-hour drive into a 9-½ hour drive.

Luckily, it was worth it. The remoteness and beauty of the beach was spectacular, the weather perfect and water temperature refreshing without being cold. We wanted to make it to this particular beach not only for those attributes but also b/c of the fact that it is sea turtle nesting season. The two main sea turtles that are abundant in that area are the loggerhead and the leatherback turtle. The loggerhead is quite large but small in comparison to the massive leatherback. The carapace (shell) of each is quite different, making identification relatively easy. The carapace of the loggerhead is the typical mosaic pattern found in many turtles. We saw a few of these turtles the last time we went scuba diving in Sodwana Bay. I was able to get close enough to gently touch it’s back in the water. It is amazing to watch them swim. The leatherback’s carapace has longitudinal ridges running along its back and its texture is more like hard leather. They can get incredibly large and don’t like to move too far on the beach to lay their eggs because it is too much of a work out.

For a few months out of the year, these turtles come back to the same beach where they were hatched via an internal “GPS” system and waddle up the beach before making a large sand “nest”. Once they settle into position for laying eggs, they enter a hormone-induced trance and can lay over 100 eggs. They then gently bury these eggs and in a couple of months they hatch. Upon hatching, these little buggers scoot like mad for the water, while registering the location in their internal “GPS” system for later use. 12% of the eggs are eaten by ghost crabs in the nest. Only about 2 in 1,000 eggs make it to a full adult turtle. Birds, larger fish, and other predators have a feast as these baby turtles try to make it out to deeper sea and safety. We saw many turtle tracks on the beach and their nests but did not actually see any turtles on the beach. The tracks of the loggerhead are about the width of a 4 wheeler and the leatherback more like the width of a small car. The picture of tracks here are that of a loggerhead.

The dive instructor said that these sea turtles have been around since the fall of the dinosaurs. My nephew Ben apparently tells grandma this fact all the time. The instructor also said that they are predicted to go extinct in our lifetime. So, it has been a great experience to get so close to such amazing creatures.

We did get a chance to go scuba diving over the weekend as well. The visibility wasn’t great but the biodiversity was. Highlights were a blue-spotted ribbon tail stingray about the size of the hood of a car and directly behind it some sort of electric ray. The honeycomb eels were abundant, along with lionfish, angelfish, snapper, nudibranch and others. Definitely, a highlight of the last two trips was dolphins playing along side our boat within feet of us for a long time. Last time we also saw a whale surface. After our dive, our dive master mentioned that at that very reef they saw an 18-foot great white shark on their last dive. They are common along the southern shores around Durban and Cape Town but more unusual around this area. Not sure I would have been too enthused to dive had I known that. I am sure that is why he waited until after the dive to tell us. In Cape Town and Durban you can do cage diving – where they take you diving inside a steel cage in Great White Shark infested waters. Your chance of seeing one is quite high but I am not sure what kind of environmental impact this has. You definitely don’t want these animals associating humans with food! On the other hand, it would be awesome to view one underwater……

FROGS

For some reason, unknown to us, frogs have been visiting our home on a nightly basis. Almost every evening, without warning, we notice a large frog in the middle of our living room floor. The doors are shut tight, there is no discernable passageway to the outside and we cannot figure out how they get in. Once is interested, twice is unusual, three times a bit bizarre but every night? We usher the frog outside each evening, shut the door behind him/her and they are out for the evening, only to magically return the next evening.

We are starting to think it is in some way symbolic. Isn’t there some Chinese symbolism in a visitation by frogs such as this? When I mentioned this to a friend he, in a very practical manner said, “I will tell you what a visiting frog means, it means that you are going to have visiting dangerous snakes trying to eat those frogs!” Not settling news given that there are some very dangerous snakes in the area including the black mamba, Mozambican spitting cobra, puff adder and gaboon adder. A black mamba bite has the potential to paralyze you in a matter of 15-45 minutes depending on the amount of envenomation….a bit frightening indeed. The anti-venom is available but not that easy to obtain. I took a course in snake first aid in southern Africa, fascinating and frightening at the same time. The others can do some damage but none as deadly as a black mamba. Fortunately, they are shy and skittish. It is rare to see one. The three of us who took the course soon after went camping in a beautiful nearby park. We asked a friend from here if there were any black mambas in the park. She flatly replied that our chances of seeing one were zero. She had been hiking in the park hundreds of times and never seen any snakes. The first evening we arrived to our campsite after about a 7 km hike, set up camp and were relaxing around the campsite. Paul started going for a walk down the trail. Soon after I heard some talking that turned out to be yelling. I heard him yelling, “Dewey, come over here”. I thought he might be having some trouble so I jogged down the trail to find him excitingly pointing out about a 5 foot black mamba that he had come across. I asked him, “and I am coming this way because….????” We watched it slither into the grass and up a rock face knowing full well of its potential and potency of lethal envenomation. Frightening. We camped two nights and hiked all over the park and it was a great weekend. We didn’t see any more snakes but believe me, we were watching out steps.

Back in Swaziland

We returned to Swaziland after a whirlwind tour in the US. I passed through 7 different airports in the US alone during the course of 3 weeks. It was a bit hectic but great. We did back to back weddings, Saturday night in Duluth, MN until 1:30 am then to the airport by 4 am and off to San Fransisco in order to make it to northern California for a wedding on Sunday afternoon. Both were great and it was wonderful to be there with most our closest friends in both states. Yeeeebo! Congrats to Barry & Amy, Kevin and Jolaine.

We were able to see our families in MN and fortunately be there for the arrival of the first Dewey girl in over 80 yrs! Isabel Rose Dewey had to come out and meet her aunt and uncle before they returned to Swaziland (just a couple days before)! We were very happy about that.

I also made a side trip to Tennessee of all places to interview for a couple of fellowships in Emergency Medicine. More to come on that in upcoming blogs. Mom and dad made the trip with me and enjoyed some music, some Colorado Bulldogs (Mary Ellen) and some BBQ. We had a fun trip, saw some music and got my parents to try sushi!

All in all it was a great and exhausting trip. Arriving back in Swaziland to our quiet lifestyle was almost a relief. It has been raining a lot in Swaziland these days but we are still loving our house by the rock.

I missed the children of Swaziland when we were gone. It continues to be an emotional experience in a good and difficult way at the same time. My first day back I saw many sick kids and was doing a spinal tap within hours of going back to work, shocking me back into the realty of what childhood means to an HIV positive child in Swaziland. The suffering continues and the healing happens.

I traveled to my usual outreach sites twice in my first week back. At one site I see mostly pediatric HIV patients and a few adult HIV pos patients. I saw 16 children and one adult. I recommended starting Tuberculosis treatment on three children whom I thought had active TB, 3 children were on anti-TB meds and 2 had been recently treated for TB. That makes 8 out of 16 children that had TB! Some were extremely sick and near death. One child who had already been treated for TB came in respiratory distress and clearly had a bad pulmonary illness. I listened then sent him for a chest x-ray finding that his entire right lung was infiltrated with an infection. His left lung also had a smaller infiltrate.

On the Thursday, I went to Emkhuzweni, as usual. I arrived there to a mother and baby in my exam room waiting for me. I was unpacking my things when my translator tapped me on the shoulder to look at the 16 mo old, 10 lb girl seizing on the exam table. She had a temperature of around 104, seizing, breathing fast and generally not looking well. I brought her to the hospital and we put an IV in her scalp vein, gave her valium to stop the seizure and antibiotics. Likely she has meningitis but possibly a febrile seizure from another illness. I think she aspirated b/c of the seizure and was breathing fast later in the day. I have seen that girl about 7 times in the last year, treated her for TB, Pneumonia, infectious diarrhea and now meningitis. It has been difficult to get her well enough to start anti-retroviral treatment. I have wanted to start but you cannot start them when someone is acutely ill. She has had a fever 5 of the 7 times I am seen her. She has suffered and I can only continue to hope and try to get her on ARVs before it is too late. She is a beautiful girl who has had a tough go at life thus far and I just hope I can have the opportunity to set her on the healthy path. The next two patients had severe edematous malnutrition of which the prognosis is very poor – Kwashiorkor. Neither had any form of milk since breast feeding was stopped, mostly due to poverty. A daily liter of milk is about a dollar a day and most families live on about $25 dollars a month for the whole family. Once breast feeding is stopped, many rural families cannot afford replacement milk. Formula is ridiculously expensive and simply out of the question for most of them Water sources are unsafe – most use river water, often not treated/boiled leading to infectious diarrhea. Not to mention with a fair frequency people get mauled by crocodiles when trying to fetch water in the river. Life aint easy, life aint easy.

So, given these experiences, it is difficult for me to flip between the two worlds. One of privilege, comfort and excess vs one of disadvantage, discomfort and minimalism. Both worlds have happy and unhappy people, which makes me ponder where real happiness comes from. Not from a big mac but not from a crocodile mauling which fetching dirty river water. I continue to feel lucky for what the card I drew in life. I hate to should people….but in this moment I will. We all should remember to be thankful for the good things in our lives, appreciate them and celebrate our clean water, food on our table, shelter over our heads, comfort in our lives, love of family and friends, people who we can lean on. Not everyone has these things. So, the next time life in the fast lane pisses you off, lean back in your easy chair and re-evaluate. I won’t should again but these are the thoughts I have when shifting between worlds. Go for a walk, shut off the TV, call your loved ones, plan fun trips, listen to music, appreciate the night sky, eat in moderation and relax.

The Fire

Photos: the fire, the fire stick and the char the next day

It is now the dry season in Swaziland and it looks a bit like Sonoma County with golden undulating hills. It is truly a beautiful country with granite boulders and small mountain ranges. Pine Valley is loaded with tall, dry grass, dead trees and dried leaves this time of year – a perfect set up for fires. Typically, locals create a firebreak around their houses so that if fire does come toward their house, it stops at the break. The firebreak is usually a ring of pre-burned area surrounding your house. In addition it is advisable to keep the grass very short in your yard and have no downed or dead trees next to your house. Lastly, houses built of wood with thatched roofs pose an additional fire danger.

Our house has a metal roof and is built out of brick, good news. We have a gardener who does a good job of keeping the grass short but did not put in a firebreak. Daily fires are common in this area. A month ago there was a large fire burning the hillside that caused us some concern. That is when we discovered that although the fire department was called, they did not show up. Neighbors notified us that if they did come, they would likely be using long sticks with rubber flaps on the end to beat down the fire. No water supply and hoses or anything of the like. There would likely not be a very large team. After that intro, we were asked if we wanted a stick and to join in the neighborhood firefight. It did not seem like that much fun at 10 pm with work the next day. After surveying the area, it became clear that lots more would burn but that it would reach a small creek and likely be stopped. We went to bed and in the morning saw that what we expected to happen is exactly what did.

Last Monday, when getting ready to go to bed I noticed some large flames on the hillside above and to the north of our house. I had been hiking in that area and knew that it was all excellent fire fodder from the flames right down to our house. We realized at that point we wouldn’t be getting much sleep that night. Sure enough the flames progressed down the hill toward our house. We took a drive down the road to survey the scene – no creek to break the flames. We found the origin to be at a distant neighbor’s house that likely was trying to create his firebreak and let it get out of control. Seems to be a common phenomenon each year. Soon, the entire hillside surrounding our house was in flames. By 2 am enormous flames were approaching. Our landlord had come over earlier and given us his fire fighting sticks. He then had to leave, after a call from his wife, because the fire was approaching his house. We packed our computer, passports, money and other valuables in the car, opened the gate, and pointed the car out in the get away position. Ash, smoke and flames soon were on all four sides of our yard, crossing the fence and burning our grass. Angela was using our weak hose to put out what she could and I was running around with the fire stick (pictured) beating down the flames. Fortunately, since the grass was short, the flames were fairly small in the yard and we were able to head them off in all directions.

I think the level of danger was less than it felt because it was likely that the entire yard would have burned and then stopped. Since our house has nothing flammable on the outside, likely nothing really would have happened. Nonetheless, it is frightening to have your fence line surrounding by billowing flames, ash and smoke and no fire department. We went to bed after 3 am feeling smoky, eyes irritated and exceedingly tired. It was a long day at work the next day. Angela was recovering from a long coughing illness at the time of the fire; I was recovering from a weekend of extremely strenuous hiking in the mountains of Malalotja Park. Neither of us was ready for a night of duty on the Pine Valley Fire Department.

Sibebe Rock, our new backyard

ok, where was i...

We moved into a new pad and it is fantastic. We are now country dwellers. We live in the countryside but only a 15 min drive to work. It is a small brick cabin in the woods kind of place with a nice fireplace, patio, loft and amazing views. We basically live in a park. Our backyard is the largest single piece of granite in the world. Google it - its called Sibebe Rock. Last weekend my friend Ryan and I climbed to the top. It was a bit hairy in parts - very steep. We made it to the top and so did the dogs. There are 4 dogs at our new place. 3 came with the place and one is a stray puppy that showed up yard at the old place. That makes for good security. Our house is in Pine Valley, probably one of the most beautiful places in Swaziland. In the picture of us climbing the rock, our house is below with the green roof.

Work, hmmmm....Always busy and always challenging. The sicknesses, death, dying, misunderstandings, baracades, cultural and gender barriers can make it difficult to swallow. My outreach work continues and I have been traveling to work in small clinics a lot lately. We do have successes, children get healthy, babies turn out to be negative, opportunistic infections cured and smiles return to the faces of these lovely children. Lately, I have been seeing greater than 25 patients, round trip driving of 3 hrs leaving little time to finish all the patients. The patients in outreach are sicker, more malnourished, lower socioeconomic status and less knowledgeable about ARVs and HIV. Most of the patients are women and children. Men rarely come to our clinic but yet have most of the power in the homestead. Most of the time the women need to get permission from their husband or father to go to the clinic, get tested, start ARVs etc. In one situation recently a mother brought her child to be tested and enrolled in care. The child was 6 months old, the mother could afford formula so we recommended weaning to prevent transmission of HIV (current recommendation by WHO in HIV pos women is to exclusively breast feed for 6 months then wean if she can afford other forms of milk). She stopped breast feeding, disclosed to the father that the child was tested. He got mad and stopped buying milk for the child. Now when I saw the baby at 8 months of age, he did not have any form of milk for 2 months because the father was mad. Challenges, challenges….

Angela is doing quite well, working for Young Heroes orphan relief program. She is busy preparing for a benefit concert coming at the end of September. She loves our puppy even though she is quite a troublesome dog. We are traveling to Nisela this weekend where she will do some safari stuff and I am taking a course on dangerous/venomous snakes. I will be learning identification of snakes, first aid for bites and types of venom. Needless to say, Angela was not interested in that course! We are both looking forward to our visit home at the end of August. I am still trying to iron out the dates but hoping to start the travels home by august 24th and spend 3 weeks stateside. Looking at the first and third weeks in MN and the second week in California. We plan on going to Breads wedding (Barry and Fred) in MN then Bealmans (Beal and Bergman) wedding in California. Also may give a grand rounds presentation in Santa Rosa on the 5th of Sept. Should be busy but great. We are looking forward to seeing family and friends.

That’s all for now….
Dan

The infamous PU

Driving home from another day in rural Swaziland doing out reach I spy the infamous PU (aka public urination). This time the back is not turned and the teenager is at the top of a small hill urinating directly at the main road. Angela and I started hitting the roof of the car each time a PU is spotted, much in the same way that we hit the roof when a VW bug was spotted or a car with one headlight was spotted growing up in MN. PU does have its advantages though. It was perfectly acceptable for me to use the facilities directly behind the rural clinic I was visiting two weeks ago. Quite nice, I must say. So, if upon return to the US, I decide to PU when the urge hits me, please understand. I will write it off as “cultural re-adjustment”.

Today was a light day in Emkhuzweni because I only saw 16 patients, drew blood on about 10 including several jugular vein sticks on the small and febile. A few days ago was a bit tougher – probably 25 patients and more blood draws. There continues to be successes and failures, thus is the work here in Swaziland. For every failure or suffering child there is a smiling one behind them who used to suffer. The concept of “you win some and you lose some” applies and is the only way to keep moving forward. I have patients who die or are dying every day. These children are resilient and strong but they continue to suffer. The physical and emotional suffering is what both repels me and draws me to come back the next day to try again. There are so many that are benefiting from treatment and it is not at all doom and gloom. You just always have the feeling you could, should and want to do more. I can see how people in this field get burned out. Today I saw a 12 month old boy with the weight of a newborn who was benefiting from care. I saw him twice with a fever and got him a referral for TB work up. He was diagnosed with TB, started on TB meds, I treated him for oral thrush, malnutrition and diarrhea. Now he is eating and not febrile. Doing better but his skin still hangs off him like an 80 year old and his veins are difficult to access so I drew blood from his neck. I am always thinking about these children as I make them cry and scream. We make them suffer more in an effort to help them in the long run.

Angela is doing very well, still working at Young Heroes and seems to enjoy it. She has a trip coming up to Botswana and Zambia with her friend Jenny. Sounds fantastic. Jen is a travel agent and Ange is going along on a trip where they fly in to bush camps daily in Northern Botswana. The lodges look fantastic and it will be an opportunity of a lifetime to view wildlife. I am looking forward to hearing about the trip and seeing the photos.

another day...

Looking back and reflecting on my day yesterday made me note what a shocking world this is. Here’s what my day entailed yesterday:

I arrived at the clinic at 7:30, well actually we were on Dangela time and arrived at 7:45. Some things don’t change….I was greeted by a room full of beautiful children and their families. Always a pleasure to see such appreciative families but also sad to see such a room full of needy patients. I was scheduled to go to a romote clinic in Emkhuzweni yesterday leaving at 7:30. The delays were in motion. I had to see a follow up patient – a sexual abuse case. Being paternal in these cases, I didn’t want anyone else to see this child. I finished prescribing this child’s ARVs for post-exposure prophylaxis, counseled the family and rushed out the door for the 1 ½ hour trip to the outreach site.

After avoiding cows on the road, picking up a dentist and a nurse on the way, stopping at a government lab, a Kentucky Fried Chicken stop for the driver and meeting a parliament representative we arrived part way. We stopped at a clinic in Dvokolwako (or something like that) where I was asked to see a mother and her new born to give advice on what medications to give for PMTCT (prevention of mother to child transmission). The mother came to the clinic once for HIV testing during her pregnancy but could not afford the transport to return for her CD4 results. While in labor, she tried to come to the hospital to deliver her baby but had to walk. She collapsed half way there and was brought back home and delivered her baby at home, not getting the ARVs she should have had during her labor. A few hours later she found her way to the clinic and saw the nurse who had questions about what to do. No meds during pregnancy, no meds during delivery, now what? Fortunately I was able to give advice and a prescription. How can you rush on in our nice clinic car when a mother like that needs your help?

Finally, we arrived at Emkhuzweni to a room packed with expecting mothers or mothers and their newborns. They had been waiting all morning for the doctor (me) but I arrived finally at 11:30 am. These poor rural Swazi women were nothing but appreciative to see a doctor. I was happy to give advice, prescriptions and ponder very difficult decisions in order to try and prevent yet another HIV positive child. I had to draw my own blood which I have very little experience with. The nurses always did that for me in my residency. Adults were easy but the 7 week old patients were difficult considering I had never done it before. Those are some small veins! I did have some good success and it was great to learn a new skill. Don’t worry, I was very careful. Many of the women walked a long way to see the doctor and get care. They are trying but fighting difficult foes – poor food security, no transport, no money, little male support, HIV stigma, opportunistic infections, doing manual labor daily while pregnant, walking long distances etc. It makes me want to give them my best. Finally, I finished – making many people wait and work overtime before making our journey home in the rain. A typical day. I will be going there every Thursday and some Tuesdays.