Can you believe I've been here a month?

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.