The Home Based Care Team

I thought that it was time to introduce you to the Home Based Care team that I volunteer with. Usually people here call it the Home Base Care team, although hitting a home run here in Swaziland is difficult at best and nearly impossible given the million obstacles to providing effective and sustainable health care. Whether you are in the hospital or out in the field, the complexity of the situations you are dealing with easily becomes overwhelming. I am always amazed when established goals are achieved. You start out on a visit envisioning that you are going to do some basic symptom management and end up finding that there is a new orphan on the homestead who wasn't there on the last visit, or that the patient has now contracted TB to go along with their HIV, or that the patient you paid for transportation to the hospital to have her CD4 count done arrived only to find that the CD4 machine was 'not working' and basically spent an entire day only to find out that she needs to come back again. The idea of providing holistic care in rural Swaziland is beyond me, once a new psychosocial or physical symptom has been identified there doesn't appear to be anywhere to turn for assistance. The systems in place are completely overwhelmed and the traditional culture and family that functioned quite well forty years ago no longer exists with an HIV/AIDS infection rate of 42% and life expectancy of 32 years.
The language barrier is also a huge issue. Having to rely on another person to translate while hoping that he or she is not inserting their own value system along with what you are saying can be a great obstacle. Even not knowing the language it is often clear when someone is not understanding what you are trying to relay. For example, when you ask to have it translated that you must get to the hospital to try and get started on ARV's or TB treatment or it is likely that you will die in the next several months and the patient has not altered their expression then you know that your concerns are not being heard. Given the level of frustration and obstacles presented we as a team are still able to provide some medical and psychosocial care and a needed parcel of food. It is very rewarding when you review a patient's medication card and find that they are taking their medications as prescribed or the child you treated for worms appears to be less bloated or that the woman with all of her facial bones and ribs protruding has now gained a couple of pounds. When this happens, it makes it all worthwhile and it helps me to return the team the next day.
Some of the team members have been doing Home Based Care for many years and it truly amazes me that they are able to keep returning to the field. I have to congratulate them for their efforts and their strong commitment to what they are doing to help their countrymen and women. Kathleen Hartman RN from NYC and Anna Zwane RN from Good Shepherd Hospital started the HBC program informally in 2001, gathering whatever medical supplies were available and buying food at the local market to distribute to home bound patients. This was long before any ARV's were available in Swaziland, and what they faced was an epidemic of dying men, women and children with nowhere to turn for hope of viable treatment. Over the next several years the team became formalized at the hospital with its own staff, supplies, vehicles and oversight. Currently, there are 22 communities that are visited on a revolving basis, serving anywhere from 20 to 30 patients and their families daily. There is a movement within the teams organization now to serve fewer patients more thoroughly and holistically, although we can never turn our backs on a patient who walks up to the HBC truck looking for care.
Here in Swaziland it is very important to identify who has what role and to identify them accordingly. Nurses are referred to first by their title and then their surname. It is rare that you ever hear anyone being addressed by their first names if they have a position of authority at the hospital. Even when we ride in the truck to make home visits the most senior member of the team sits in the front seat and is basically referred to as the decision maker. What follows are a brief description of the team members, volunteers and visitors.




Sister Jelle.
Andrew Jelle is an RN. Sister is the traditional title given by the hospital for the role of manager of the team or department. Obviously this title has been carried over from the days when all the nurses were nuns or lay women.
Andrew oversees the team now, making most managerial decisions. As a measurement of time, Sr. Jelle has benefited most by my presence as a volunteer here. He rarely makes home visits any longer although he continues to manage the team.





Matron Zwane.
Her title as matron comes from her previous role as the Director of Nursing for the hospital from which she has retired. She came out of retirement, I believe that it lasted for all of a week, to be instrumental in starting the HBC team. Anna Zwane is basically the heart and soul of the team. She is tireless in her efforts to serve the patients and people of Swaziland. She has the greatest knowledge base of the history and needs of the community and is generally right on target about what patients to see, when and what their needs might be. She also has an incredible sense of direction, directing the driver of the truck (me) when and where to turn, stop and start, often down foot paths that you would think could never accommodate a pickup truck.

Although you would be hard pressed to believe it, Matron Zwane will be turning 70 years old this year as well as celebrating her 40th year of nursing in July. While making a home visit we came across a group of boys playing soccer and Matron Zwane joined them for a couple kicks of the ball, much to the boys' amusement and joy.

Below is Deborah Maphosa. Make (pronounced ma-gay, which means mother or Mrs.) Maphosa as she is referred to in the community and by the team and our patients. She is standing outside of our HBC office, and behind her you can see the line for the Out Patient Department that has formed in the early morning. Make Maphosa is incredibly sweet and sensitive, she connects very well with the patients and their families and can personally relate to their issues and sorrows. She is the head of her household, 10 family members live with her, she raises several grandchildren who have lost their parents and is the only person working in her family. Deborah is a nursing assistant, although she takes on the role equivalent to an LPN in the States. It is not unusual for Make Maphosa to break out in prayer when it seems most needed. She sings and prays beautifully with her whole heart.
In the following photo are Valerie Kalungaro, a registered nurse from the Congo, our patient who we refer to as simply Mkhulu (pronounced ma-kool-lu, which means grandfather) and Anna Mary another nursing assistant, again who would function as an LPN in the States. First a brief description of Anna Mary, the woman on the right. She lives in Manzini and has an hour commute to work every day, which indicates to me her commitment to the HBC team. Her strength lies in her ability to counsel patients in the field, often encouraging patients to get tested to determine their HIV and/or TB status. Often she is the nurse along with Make Maphosa who sees our patients on the wards and again does counseling and follow up for their anticipated hospital discharge.
Our friend and patient, Mkhulu, is always pleased to see the team and often requests a kiss from the women, especially Anna Mary. He lives alone on his homestead, takes great pride in keeping it clean and orderly. He is suffering from congestive heart failure and has the most appreciable heart murmur that I have ever heard. I am always surprised to find him alive and kicking each month. He has lost a significant amount of weight in the past couple of months and is generally quite fatigued.

















The above photo of Valerie really seems to capture her spirit. She has been the most welcoming person and is always willing to explain what is happening and is tireless in her commitment to work. She is the first person to get out of the truck to open a gate, chase off the stray dogs and to always carry more than her fair share of supplies. We constantly squabble over who will carry more, she or myself, most often I win. She promises to visit us in New York, so hopefully you will get a chance to meet this amazing woman. Valerie and her husband (who is an doctor at the hospital) are from the Congo and have been living in Swaziland for about 3 years now. She had to learn English and SiSwati at the same time and has managed to do very well. Now she is basically fluent in 7 languages: her top two are a dialect from the region she grew up in and French. We often share French phrases between each other, although she thinks that David's French is much better than mine, so she's not perfect. Many of her sentences start with 'in my country' and often end with a contagious laugh that basically has little or nothing to do with what we are talking about, and it always brings me great joy. We have fostered a close relationship with Valerie and her husband, enjoying occasional drinks and meals together. Our initial connection was fostered by her admiration for President Obama and the hope that he will be able to stop the fighting in the Congo so that she might someday return to her family, children and grandchildren.







Kathleen Hartmann RN. As I stated earlier, she was instrumental in starting the HBC program at Good Shepherd Hospital. Additionally, she was a CMMB volunteer and the person who first made me think about volunteering here in Swaziland. It is her commitment and love for the Swazi people that led me the HBC team. Currently, Kathleen is here at GSH helping to support the team for six weeks.




Karen Wong RN, (our dear friend from San Francisco). While she was visiting she instantly became apart of the team, making numerous home visits with us. She immediately connected with the team and the patients as only Karen can do in such a short time. Here Karen is pictured with an old Gogo during a home visit in a neighboring community.

David sitting on the back of our HBC truck with one of our young patients. Frequently, but not often enough for me or the other team members, David comes along on our visits. The children especially like his salt and pepper hair, how tall he is especially compared to the Swazi's and like to stroke the hair on his arms; it is really cute to see. Generally we put David to work distributing the food parcels and keeping the log of patients seen that day.

Here I am on a home visit with a couple of children from the homestead we are visiting. The child on the left is a patient of ours while the one in pink is the infant child of one of our patients. The children are most endearing. Here, and in Africa in general, children are much more visible than in the States. Besides running freely at the homesteads, you often see them on their own along the roads going to and from town, school, or running other errands, a very unfamiliar sight back home.

Peace,
Scott