This is it

This will be my last post from Africa and boy I'm all churned up. I'm just nowhere near processing this experience so I don't think I have anything coherent to say. And I suppose the wine I've been drinking doesn't help in that arena. I did notice that I'd been doing an awful lot of complaining about the nursing here and I'd really like to correct that picture a bit. First of all, I see a hell of a lot of nursing that pisses me off right in my own backyard in New York. The problem here is that they haven't yet figured out how to transition the nurses from didactic to practice. To be perfectly honest, this is exactly the problem I see with the nurses in my own agency, so it's a hard nut to crack. They absolutely need a lot of help here. More than we do. Much. But there are some nurses that I have met here who are almost heroic in their ability to work with nothing and yet make a positive difference in the lives of the people they care for. I want to tell you who they are.
Khawulile Magagula - In-Service Coordinator for the hospital. My counterpart here and one of my favorite people. I plan to keep in contact with her.
Sandile Malaza - I met him in the Men's surgical ward. He is now the Infection Control Coordinator and it's scary how much they need him. (You wouldn't believe what I've seen)
Lukhele Bongani - Staff Nurse in the ART clinic. It took a while for me to get him to trust me, but once that happened, we had some wonderful talks.
Sanboy Mamba - A clinical instructor in Community Health. I went out on home visits with him and some students. He is a wonderful teacher with a truly open mind.
Hlengiwe Mohale and Love Kumi - You're not going to believe this but both these women are Maternity/labor & delivery nurses, unfortunately not there much when I was. Betty worked with them a lot and they have the potential to turn that ward around.
Simon Banda - RN lecturer. He had just the right amount of outrage over the situation along with the ability to communicate productively. I hope he comes to the States.
I'm going to miss them. I'm going to miss how open and welcoming they were to me. I'm really going to miss the work now that I know better how to do it. And I'm going to miss Africa. So much. Oh hell. I'm tipsy and I may start crying. Kevin and Sheldon, who I've grown to love in one week, are off to Mtubatuba for the weekend so I've got my final night here all by my lonesome. This leaves me way too much time for reflection. Alright. Enough. I fly out tomorrow. I'm surprised at how much I've enjoyed keeping this blog. Thanks for coming along. See you next week. Carter - you owe me dinner.

My Last Full Day at Work

I can't believe this is coming to a close. I will say, however, that this last real day at work truly was a culmination of all that I have learned.

I decided to face my most disturbing placement and see how I would function now that I've gained some experience. I went back to Labor and Delivery. Once again, I witnessed no nurturing of these women, or assistance given to them with their labors. Since the room was open with no curtains drawn, and my actions have to count as "mentoring", not just nursing, I was able to do the work and mentor at the same time. I applied massaging pressure to the lower backs of 2 women who demonstrated reduced muscle tension and more even breathing. One woman, during the pushing phase of her labor, was laying with her head and back flat on the mattress. She was being yelled at to push but was unable to gain much traction to make her pushes effective. I suggested that perhaps if her back and shoulders were elevated it might help her. There was a slight nod in response but no move made to elevate her. I slid my arm under her shoulders and told her to look at me when a contraction came and that we would push together. She looked at me and nodded. Then she looked up at me, tensed up, I lifted her shoulders and encouraged her to push. I praised her. The baby came. The mother looked at me and smiled. She squeezed my hand and laughed. The preceptor looked at me and said “Thank you. You really helped her”. I know this seems like something that goes on all the time in delivery rooms but, I'm telling you, it doesn't ever happen here. My goal was to show that, by working with the mother rather than intimidating her, labor actually proceeds more effectively. It is a moment I will never forget. Ever. Just peak. I think it may be the most important mentoring I’ve done yet here. Of course, 10 minutes later I saw another nurse yelling at a laboring mother and actually slapping her legs to get her to open them wider. It was sadistic. I hope that at least the preceptor I worked with will encourage the student nurses to assist the women who are laboring and not continue to treat them like misbehaving children or worse. I have seen and met some truly wonderful nurses here, working in unimaginable circumstances, but this ward is scary.

The second half of the day I spent visiting 2 groups of AIDS orphans in rural areas about 45 minutes outside of Manzini. I wanted to post a video I made, but I seem to be unable to complete that process without error. I will try even after I get home. They are beautiful and their situation is heartbreaking and that's all I have to say about that right now.

Tomorrow there is a ceremony for the first year students. Then I pack. On Saturday I fly home. I'm ready to go home. I miss Stephen and Liam and Stella too. But I want so much to come back some day.

My Final Week

I just cannot believe that this is my last week here. I've spent so long looking towards this trip. I'm concerned how I'll feel once I get home and no longer have this in my future. I guess this is just to say, I'd really like to return.
I'm here now with Sheldon, a nurse who is also a Professor at the University of Rochester, among many many other things, and Kevin, also a nurse, who is a Professor at Georgetown and is one of those running this program. I like them very much and we've actually been having a lot of laughs. Kevin got in on Saturday night and on Sunday he and I went to Phophonyane Falls and hiked around in the off and on rain. It was so beautiful and I'm frustrated that I neglected to bring my camera. Sheldon got in Sunday afternoon. Yesterday was spent orienting him to where we're working and formulating a plan for the week. Betty would have been so happy and I really missed her. They seem to have turned a corner and, now, all the work we wanted to sink our teeth into for the past 3 weeks is available for us to do just that. This makes it doubly frustrating that I'm leaving soon. I want one more month. Ah well. Maybe next year?

Today, Sheldon and I went with the HIV Task Force to a support group for HIV+ people. It was a wonderful group which was actually being interviewed by a related agency. I was able to ask questions of the group members about the difficulties they encounter adhering to medications. The main obstacles they face begin with a severe lack of food, followed by lack of access. They have to go so far, most often on foot, in order to get to a clinic. These long distances make keeping up with medications almost impossible. Lastly, superstition was reported as a problem for some people, although not members of this group. The belief that the medicines don't work or are poison is very common. It was a great group to be a part of. After that, we all piled into cars and vans and we were shown "The Garden Project", a community garden created with outside funds. It was beautiful, although right now its main crop is potatoes.
And finally, we went on a home visit to a mother with newborn twins. This was when I wanted to scream about leaving in a few days. There is so much more work I could be doing. She had done such a wonderful job staying adherent to her meds, increasing the likelihood that her children will have been born uninfected. I praised her for what a wonderful mother she is and when we left her hut the woman running this program said "She shouldn't be having babies". She didn't seem to have any idea how not helpful a statement like that is. Exclusive (meaning no water or food at all) breast feeding for the first 6 months is the best thing for an HIV+ mother to do when there is no clean water available for mixing with formula (never mind the risk of watering down formula when there isn't enough money). I asked if this mother is breastfeeding and the woman running the program (let's call her Mary) said that she had told the mom to exclusively breast feed one child and to formula feed the other!@#$@! I, calmly, asked why. Mary said, "because I don't think she can handle breast feeding both of them". And I'm thinking, "so which child is she going to choose?" Which one will have a higher risk of death by diarrhea? I talked about how helping the mom get food for herself, rather than formula, would make her better able to exclusively breast feed both kids, decreasing the risk of HIV infection for both and for intestinal disease for one. If she's unable, then you could start formula, which you would then have to stick with so as not to risk HIV infection with reintroduction of breast milk. I don't think she really thought much about what I said. I hope to be going out with the HIV Task Force again on Thursday. Perhaps I'll have an opportunity to readdress this topic. Although it will be too late for this mother and at least one of her children. I hope so much that they stay well. I will have to provide "Mary" with lots of information to give them about how to disinfect water. I wish so much I could visit that family again. I know I won't forget them.

My friends leave today

Today is a bit of a milestone. We've hit the 3 week mark and Betty and Linda are leaving me. It is an understatement to say that I will miss them enormously. This kind of experience lends itself to substantial bonding in a quite brief period of time. Yeah, I'll really miss them.
Yesterday, for their final full day here, we went to Mkhaya Game Reserve for endangered species. Because these animals are endangered, the park tries to eliminate or cut down on kills, so there are no cats in this game park. It seems I will leave Africa without having seen some. I can live with that. I've seen so much. For instance, we were able to get out of the Land Rover yesterday and get pretty close to the Rhinos. I have more wonderful images of Giraffes and Elephants. I call this one "Giraffes Two by Two". I still have an impossible time capturing Hippos. I've seen a lot of them, but everytime I'm ready to click, they dunk back under water. Cagey suckers.


The Rover we were in yesterday had no cover and the unobstructed sun beat down on us hard. I actually began to feel as if I might not be able to complete the drive. Feeling severely dehydrated even though we were drinking water constantly, during our stop for lunch my friends and I bought the only hats available. They saved us, but I'm still massively sun burnt on my shoulders, my upper chest and the back of my neck.

I kept waking up thoughout the night. Nothing new about that. But then the phone rang at 4:50am. Liam called to let me know that his call-back for Brighton Beach Memoirs (sent via dvd) had been seen by Neil Simon, who really liked it, and now he'll be headed back to NYC tomorrow to audition again for Jay Binder on Sunday and for Neil Simon himself on Monday!!!! Go Liam! Then I had to check out his auditions on YouTube and then I had to kvell and kvell and kvell because my baby is such a good guy and so ridiculously talented. Ah me.

So, I will be looking like a lobster who really needs some sleep when the new nurse arrives today. Wish me luck. I feel a bit at sixes and sevens without my two buds. I can't believe I have only one week left myself. I have such high hopes for how it will turn out.
Here's hoping.

A Schizophrenic Week

This is the longest I’ve gone without writing because I just haven’t had the heart for it until today. I’ve gone from feeling elated to blue to back again and, maybe that’s just me but, I’ve got whiplash. The first half of the week was spent working on a Procedure Manual that had nothing to do with HIV and even less to do with why we are here. All three of us were losing our minds. I thought, “Why did I come all this way to do secretarial work I could have sent via email?” It was enervating and demoralizing.
Then, a group of nurses came in from outlying clinics and the powers that be had to do something with them. Tada! I was called upon to give another presentation on ARV’s and adherence. This was great! Community Health Nurses. My bailiwick. What a great 2 hours. We really got into the nitty gritty of interventional strategies for adherence, exploring barriers and overcoming them, when to start therapy, and on and on. They even asked about how to change med administration schedules while maintaining therapeutic blood levels. I was in heaven.
The next day – back to the Procedure Manual. Blecchh.
And now today. Today. My most satisfying day yet. I actually got to go out and do home visits with the student nurses. Three weeks here and I finally got to do what I do. We drove for about 2 hours to Mpaka and Siteki. We went down roads that you could barely call paths. Very heavy brush. Normally, I work in an urban area of Swaziland such as it is. Today, the flora was truly sub-tropical and dense. The homes we visited consisted of cinder block boxes approximately 15’ X 14’ on average. Some smaller. All of the visits were conducted outside, in front of their homes. The families were very welcoming to me. Actually, everyone in Swaziland is welcoming. These may be the nicest people on the planet. I was able to do mentoring that included discussions of HIV, TB, diarrhea and Nutrition (Sorry for the specifics but it is what it is).
An interesting close to the day – On the way home we stopped at a gas station/chicken coop. Here, the clinical instructor got out, bought 2 live chickens, their feet were then bound (which kind of broke my heart), they were placed in individual bags with their heads peering out, and we rode home with them squawking all the way.

For a laugh, I’ve included a photo of me from last weekend dancing with some traditional Swazi dancers. I tried to hide but they pulled me out of the crowd. TWICE. Sheesh! I decided it would be less mortifying to just go with it.

Friday and Saturday

I had 79 final year students for the Prevention class on Friday and I had a little bit of stage fright for this one. I'm very happy about how it came out though. On a certain level it feels like if I do nothing else but that one class while I'm here, then my time will have been well spent. It was actually very good that they gave me two hours because, with this subject matter, it can take a while for a group that large to loosen up. And they did end up asking questions, though so quietly that I had to run all over the auditorium just so that I could hear each one. I doubt that they've heard sex and drugs talked about so frankly in that setting before. They seemed really grateful to finally be addressing these issues. And the beauty part was, at the end after I'd finished, a young male nursing student came up to me and wanted to talk about his girlfriend who is HIV+ while he is not. He wanted to know if what they had been doing was safe, how he could remain safe and still be loving with her and, also, how to keep her healthy. They don't start people on the cocktail here until their CD4 count hits 200. The new guidelines recommend starting by 350. His girlfriend's count was at 285. He is so frustrated and frightened for her. But it was a wonderful discussion. I'm hoping that in the final 2 weeks that I'm here, more students will come up and talk to me about prevention issues they may not have been able to discuss in an open auditorium filled with their peers.

After work, my two compatriots and I headed to Hlane, a game reserve about 1 1/2 hours away in Swaziland. We stayed over night in the camp and our cabin was actually 14 km within. We ended up driving thru the camp in the dark and every time we came up to an electrified gate, which needed opening and closing in order to get the car thru and keep the more dangerous animals away from the campers, I was the one to run out of the car while Betty and Linda kept an eye out. The next day they took this picture of me in front of one of the gates. What can I say, I'm a bit more nimble, perhaps. Or scared. You choose. Meantime, we still haven't seen any cats. They sleep in the shade of the deep brush during the heat of the day (and boy is it hot!) so they're difficult to spot in the summertime. I did see a crocodile kill an impala, drag it into the water, and flip it round and round. I know it's the circle of life and all but it was incredibly upsetting and disturbing. Yet, undeniably fascinating too. Very Mutual of Omaha.

And check out this great picture I took of trees (that have been decimated by elephants) at sunset.

Today in the Female Medical Unit

It is brutally hot here today. I'm feeling kind of oppressed by it. I spent the morning in the Female medical ward and it was an emotional experience. The women are so frail, some frankly skeletal, laying naked on their cots (because of the heat - no air conditioning). When I would come up to a woman she would look at me with pleading eyes but there was no energy to speak. I tried to make some contact, and had some success with one woman in particular who's diaper I changed (I'm not actually supposed to do that but help was needed). I helped to reposition her in the bed and she communicated with me regarding her comfort. But they were all just too weak and decompensated to speak more than just a word. The women in the section where I spent the majority of my time were all there with respiratory illnesses ranging from PCP to other pneumonias to TB. A cough would make their bodies absolutely quake. The staff were trying to treat for pain but they don't have a lot of options. They would use sort of a cocktail of diclofenac and valium. When I first walked into the ward it looked almost like a scene from a movie. But, of course, it wasn't. It was heartbreaking.
Tomorrow I teach Prevention for 2 hours to the 3rd year students, 80 of them. This is a minefield. This is a VERY Christian environment. I'm talking prayers before and after each class. This is my Sex, Drugs and Rock and Roll talk. I spoke with the Principal and asked her outright how explicit I could get. She said to go for it. I hope she knows what she's getting into. I hope I do. I'm terrified.