TBD No More

Hello Friends and Family:

So I guess it's been more than a year since I've posted here.  The heaps of shame that have been piled on me for not writing were high, but apparently not high enough for me to get over the writing hurdle!

This will be the last (ha!) post in this space, as life in Swaziland is no longer TBD -- at least for this chapter.  As many/most of you know, I  left my role with CHAI-Swaziland as of early December after 2.5 years there.  After a six-week visit to the US, Erin and I have relocated to Addis Ababa, Ethiopia.  I'm still working for CHAI, still primarily on HIV care and treatment, though my focus now will be more broadly on health system and HIV long-term financing.

Goodbye, Swaziland...

The best news out of all of this is that I now have a new blogging strategy! I've enlisted a co-author, who I know to be much better at this than me, because he r Swaziland blog lasted for three out of her four-plus years in Swaziland.  Erin has already posted three times in our first three weeks, so while I don't expect we'll maintain that rate of posting, I do hope we'll be more consistent.

...hello, Addis Ababa!

So, please redirect your bookmarks to the following site to keep up with our lives, as best as we are able to share them: http://erinandgarrettabroad.blogspot.com.  Make sure to include the "abroad" part, or you'll be stuck reading about some other Erin and Garrett from Texas who haven't posted since 2006.  At least we're more recent than them!

I don't think there's a way for me to forward the automatic emails that many of you have been receiving from this TBD blog to the new page, but if you'll forgive us the minor inconvenience you can again subscribe to receive our posts by email by heading over to the new site. Again, that's: http://erinandgarrettabroad.blogspot.com/

If you haven't seen it already

http://erinandgarrettabroad.blogspot.com/

In case you missed it: http://erinandgarrettabroad.blogspot.com/

We'll do our best to keep you posted!  Someday we may even reflect on our Swaziland experience, but given how busy we already find ourselves in Addis, I wouldn't hold your breath.  Maybe it will suffice to say that we had enough fun that we wanted to try another African country.

Happy 2013 to all.  Let me know if you have any trouble finding the new site and/or subscribing to emails.

Garrett

P.S. Keep the heaps of shame coming!  I don't think I would have even written half as much without them.

Adventures in Mountain Biking

Dear Friends and Family:

A quick note to pass along some pictures from the three-day mountain bike race that I rode last month with my friend Antz in the northwestern (and very mountainous) part of Swaziland.


The contour maps of the race are here: http://www.theswazifrontier.sz/pages/maps.htm.  It was definitely the most physically challenging thing I've ever done.  In total, we rode 180 kilometers over three days, with a total riding time of nearly 25 hours.  We didn't finish in last place, but we were pretty close.  Out of the 90 teams that started, 10 didn't finish at all, though, so we can put that notch in our belts.

Day one we took a 90-minute detour, and the first picture of me pushing the bike up the hill is at the top of "too brutal" which you can see on the map linked above.  That's Antz riding behind me, but for the record, he started riding at precisely that spot.  Like me, he'd been pushing for the last three uphill kilometers or so.  

Grandpa Ken, if you look closely at the first picture, you can see which jersey I was wearing on day 1.  Everyone thought I was the representative from Canada that day, though in reality that was some other guy who had flown in for the ride.

At that point, we'd been on our bikes for nearly 10 hours, but somehow still relatively happy.  I guess we were close to home by then.


Pictures two, three and four are of a river-crossing challenge on the second day, it was 20-30 yards across, and two to three feet deep in the middle. The goal was to ride without putting your feet down (picture 2).  I made it within 10 feet of the edge before tipping over (pictures 3 and 4), but ended up in the water anyway. 

  

We got progressively better over the course of the three days.  Everyone was surprised to see us at the finish line on day three as early as we were.  Our friends waiting for us at the finish had been told that we would likely arrive an hour later than when we did, so there's small consolation in that. I have a picture from the finish, but it's not with me now.  I'll try to post it later on.

Happy early Thanksgiving to all (or late thanksgiving, to the Canadians, I suppose).  We're celebrating at a different friend's house this year, but the plan is still to collaborate to cook up four turkeys and all the sides for a cast of thousands.  With luck, we'll project tonight's Patriots-Chiefs game on the wall, since watching it live isn't possible with an 8-hour time lag.

Garrett

Bug of the Day

It's spring here now, which means it's finally warming up and it's starting to rain more frequently.  It also means we get more bugs in the house, trying to find a dry spot to live.  Ants are the most common, but spiders and other big beetles can be found, too.  Nothing dangerous, at least as far as we know.

We saw a few new ones yesterday, but this grasshopper-type thing is the most colorful.  I should say that this guy was outside on the patio, not inside, so that was a bonus.

Small, But Not Simple, Steps

Hi Everyone,

A quick note to flag a recent article from the New York Times yesterday about a tactic that Doctors Without Borders is trying to pioneer in nearby Mozambique to help patients get easier access to their ARVs.

The simple solution devised by Dr. Tom Decroo, a Belgian physician working here in Tete Province for the aid group Doctors Without Borders, was to organize patients into groups of six. They would then take turns making the monthly trip to pick up refills, cutting the number of times each had to go to town — to just two a year, from 12.

It seems so simple.  Create patient groups, organize them so that instead of six people each paying every month to go from their village to the nearest clinic, only one has to.  Except it isn't simple.

The culture of HIV treatment, at least in this region, is that patients must see a clinician every time they pick up their medicine.  In the best scenario, that clinician takes a few measurements (height, weight, etc.), asks a few questions to identify potential side effects or other treatment challenges, dispenses medicine, and the patient goes on their way.  If they are sick, they are referred to a doctor or further examined for potential regimen changes.  Again, simple.  Except it isn't.

We like to think that every patient gets at least that basic level of care each time they go to a clinic, but all it takes is one visit to a busy facility to see how there's not enough time in a day for the staff to provide both the  basic care for all patients and the necessary follow up for patients who are not doing well.  It seems like we can ask for one or the other, but not both.

What Doctors Without Borders and others have recognized is that there is a major difference between a stable patient on ARVs and a new patient, and that many stable patients only need to see a clinician once every six months for updated lab tests and a general checkup.  Doing this significantly reduces the burden on both healthcare workers AND the patients themselves, who often have to scrape together whatever funds they have in order to get from their home to the clinic and back.  By reducing the number of required visits by between 60% and 80%, that's money that can obviously be used for other, better purposes, and the healthcare workers can devote more individual time to patients who are in the clinic that month.

Are there tradeoffs to this approach?  Sure.  Most worryingly, some patients will wait until their turn to go to the clinic even if they are sick or having side effects, and therefore increasing the risk of death in between visits -- though in the "study" mentioned the article no patients died during treatment. This risk, along with a general reluctance to change, makes such changes very difficult to implement at a large scale.*

That said, these kinds of creative, and simple-at-least-on-the-surface solutions are exactly the kind of thing we need to be trying to get and keep more patients on treatment.  I believe strongly that the easier we make it for patients to get medicine, the more patients are going to get it.  In Swaziland, we just recently crossed the 70,000 mark for patients on treatment.  We'd like to have 90,000+ patients on treatment soon, but the next 20,000 will be a lot harder to reach than the first 20,000.  Without innovations like this, practices that reduce patient and healthcare worker burden and improve the overall experience at clinics,  I don't see how we'll ever get there.

G

*In Swaziland, unfortunately, we're going the opposite way right now.  As I wrote in August, the financing challenges facing the government have limited our ability to purchase ARVs at a national level.  And while fortunately we again have plenty of medicine in the country, patients are now being asked to come to the clinic every month to collect their medicines.  Previously, we had been dispensing two- or three-months' worth of medicines to stable patients, again in an effort to reduce the burden on patients and healthcare workers.  The argument for giving one-month refills only is that at least all patients will receive some medicine, instead of some patients getting "too much" while others get none.  In an acute crisis, this makes sense to me, but as I look at the next six months and the fact that we have enough ARVs to last at least until then, it just seems like we'll be asking more from the healthcare staff (70,000 vists/month instead of 35,000) and requiring two or three- times as many visits from patients.  Fingers crossed we'll change that policy soon.

What We Don't Need

Headlines and stories like this in the national newspaper:

The solution to HIV/AIDS crisis?

by Mduduzi Magagula

EZULWINI – A woman who was bedridden for over a year says she has been healed by a mixture of water and oxygen.
Sibongile (last name withheld to protect her) (37) said she has been suffering from a rare illness that caused sores all over her body. She preferred not to discuss her HIV status.
The disease also caused her to lose weight and confined her to bed for a whole year.
During that time, she was also not able to do anything by herself. She said she was turned away from many clinics she visited for her sickness.
"Health officers at the Mbabane Government Hospital told me that I should stay at home without offering any medication to help my situation," she said.
Her health condition continued to deteriorate until her niece introduced some foreigners to her who offered her a bottle of medication called Oxysilver. She said a week after taking the mixture the sores on her body started to heal and she was able to eat without assistance.

The story, which ran in the Sunday edition of the national newspaper and was advertised with just the above headline written on signposts throughout all the towns (one of 5 or six stories advertised), shouldn't surprise me, I guess.  A story about some AIDS cure or other like this runs every few months or so.  This time, apparently it's driven by an American "businessman" named John Kreitzer who does at least successfully run a website listing about 10 companies in different industries and pictures of himself with Barry Goldwater and other American luminaries.  He  has, according to a companion story, written to the king to say he'll bring "investment worth over US$2 billion (about E14 billion) to the Swazi economy" by starting a factory for his Oxysilver product here.  


I'm sure he will.


I'm also sure that another set of people who are already scared and confused by HIV will be even less sure about what works as this new week begins.  I guess it highlights what an important part continuing to try to educate journalists should play in the strategy to combat HIV.  For all I know Ms. Sibongile really did get better after drinking their magic water, but I'm also sure it didn't cure her HIV, if she is infected.

Back on the Horse

I guess it's been 6 months since I've written anything.  That seems like too long a break, but with every passing day/week, it gets harder to write. So here goes.  Wish me luck, and keep up the not-so-subtle reminders that I need to write more.

The view north into Pine Valley toward Mbuluzi from our house in Mbabane

This is the view from our front lawn in Mbabane this afternoon, taken at about 5:15 p.m. or 55 minutes before the sun went down.  Strangely, the last two days here have been rainy and gray, which isn't really supposed to happen in the winter here.  Earlier this week we had near-freezing temperatures at night, but it does seem like it is starting to warm up as the days get longer.

It's been an interesting time to be in Swaziland the last few months.  The country is experiencing what the government calls a "cash-flow problem," but more and more appears to be a failure of budgeting accompanied by (or perhaps the cause of) an inability to get a loan from anywhere.*  Accurate figures are few and far between, but the government employs about 35,000 people, which the International Monetary Fund and others say is far too many for a country with just over a million people.  The government has introduced potential austerity measures, and each month threatens to implement a 10% reduction in civil servant salaries, but so far protests or threat of protests have prevented that from materializing.

Recent months have seen significant delays in payments of nearly everything.  Salaries have been routinely late, though so far have been paid.  Government vehicles that break down are unable to be fixed.  Non-essential government ministries have been prohibited from refueling cars.  Health and education spending are theoretically "ring-fenced" from the austerity measures, but it seems to be an all-out brawl to get funds each month when the revenue comes in, and civil-servant salaries have been at or near the front of the line, followed by other things including health and education.

That last piece, of course, impacts what we are trying to do on a daily basis with HIV treatment and Anti Retroviral medicine.  The Minister of Health and others have said publicly that we are currently drawing down our buffer stock for ARVs and that we need to buy more, but so far it's been difficult to ensure the financing is there to do it.  It's something we've been paying close attention to and trying to rectify, and it's an ongoing effort.  We haven't been successful yet, but we will keep trying.  In many ways it's admirable and fairly unique that the government wants to fund its own ARV procurement, so we all hope that funds will come available soon/immediately.

So that's the update for now, I still have a long list of things I'd like to write about from my request several months ago, and I'm hopeful that now that I've written something, the writers block will come to an end and I'll be a more regular correspondent

More to come...

G

*Just this week apparently South Africa has offered the government a E2.4 billion loan (~350 million USD), so it's possible that things aren't quite as bleak as they seem.  However, the IMF is here this month to review things, and by most accounts, that review isn't going to be pretty.

Kilimanjaro's Uhuru Peak -- 19,345 Feet Above Sea Level

Courtesy of Lani and Val's Flip Camera Christmas present, I present my first video entry (in HD!) on this blog.  Apologies for the out-of-breath narration and not-so-good camera work.  19,000+ feet and 8 hours of hiking will do that to a person.

More pictures and full(er) stories to come, but in short: Hiking Kilimanjaro was difficult.  We did the last day in a blizzard (see video below, click here for larger) and were at the summit at "sunrise" though in practice that only meant the sky changed from black to gray.  Of our group of 14, all of us made it to the summit at Gilman's point, and another 10 of us went on to Uhuru Peak, Africa's highest point.  We're all back in our respective homes now, 10 of us back in Swaziland, and the other four, including my high-school friends Nick Potter and Matt Flanders, are back in the US.

I do think this video gives a sense of what it was like up there, maybe hold your breath while you're watching it to bring your oxygen levels down to further simulate the experience.