Bot Doc

A Tribute

2011-12-12T21:58:00.003+02:00

At my medical school graduation

My grandmother passed away 2 weeks ago. She had just turned 88. She lived a long and mostly happy life, but had not really been physically able for the last few years and was very sick for the last few months, so it was her time. A few months ago she had a major stroke which prevented her from saying more than "Hi" and causing her to become very frustrated that she could not express herself. Despite knowing that it was for the best, losing someone you love is never easy. Being 7,800 miles away did not make it any easier. She was incredibly proud of her 3 sons, and their partners, and her 4 grandchildren. She loved to brag to her friends, and anyone else who would listen, about what her children and grandchildren were up to. She was an avid reader of this blog, when she was able and later liked to have it read to her by my father and look at the pictures. So I thought it only fitting to have a small tribute to her here.

Sonia Scherzer (Sunny as she was called by everyone, Grandmato me, and Grandma Beady as she was aptly named by Daniel (and later Sarah) -for her love of beaded necklaces) was a wonderful grandmother.

Trying on the cap and gown with her four grandchildren

Though she was clear that she would have preferred foreveryone to live and work in Queens so she could see them everyday, she wasalso proud that her offspring were globetrotters (some of us more than others). She herself loved to travel and lamented thefact that she was not able to visit me in Africa – one of the few continentsshe had never been.

I can only speak for the last 31 years of her 88-year life,but I feel so lucky to have gotten to know her so well. I think all would agree that Grandma was avery opinionated, strong willed person who could be very demanding at times,but she was also an incredibly honest, loving, and kindhearted person. She could, and would, talk to anyone andeveryone, and random strangers always felt comfortable telling hereverything. I remember several timeswhen I met her in NY City after she had taken the bus in from Queens and shewould tell me the life story of the person who had sat next to her on the busride in. Inevitably they would haveshared their problems with her and she would have provided suggestions tothem. She would go on elder hostel tripsand easily make new friends. On our tripto Israel together, when I was 13, I remember how easily she became goodfriends with the other grandparents. Though she was at times sad that she was one of the few singlegrandparents on the trip, she never let that stop her. For most of her life she had a very activesocial life of bridge games, dinners out, movie nights and scrabble. Social work was definitely her calling, andthough she was officially retired in my lifetime, she continued to provide“counseling” and advice to her friends and also to random strangers.

She was an avid reader and loved to recommend books for meto read and get recommendations from me, we shared a love of Jodi Picoult books. She was a big tennis fan as well and could watch the tennis channel forhours on end, though at the end of her life she was not always sure who was playing, it didn't matter to her. I will always have fond memories of playingtennis with her in Florida and upstate NY. Even though I was never particularly good at tennis, she never gave up onme and was happy to play and give pointers. She had a supreme patience for board games and was happy playing hoursupon hours of Monopoly or other such games with her grandchildren.

We also shared a birthday month and it was often jointly celebrated during Thanksgiving.

She was also an avid knitter and needle pointer. She, and my mother, taught me to knit and needle point when Iwas 8 and she passed her love of knitting to me for sure. She always wanted to know what I was knittingand in the last few years was excited to share her comments over Skype. She did not get to see my last few knitting projects, when I have branched out into toys....

Over the last 10 years she was so lucky to be expertlycarried for by Maxine, and in the last 2 years Charlene and Dimples aswell. Though she was certainly not aneasy patient, and not always the best at showing her gratitude, she didappreciate the loving care she received from them and I know she was verythankful that their care (and the devotion of her sons to her wishes) enabledher to stay in her home rather than having to be in the hospital – a place shehated more than any other! The devotionof her sons to caring, visiting (even coordinating schedules to make sure thatsomeone was there at least once a week – and usually more frequently), andmaking sure that her wishes were carried out was a true tribute to her and agreat example for me and the rest of her grandchildren.

At Aaron's college graduation

She will continue to live on in all of our memories andactions. For me she will be ever presentin my love for knitting, my inability to have dry eyes at special occasions(happy or sad), my strong-willed sprit, my love for travel, and my pride in andcommitment to my family. Grandma youwill be missed, but most definitely not forgotten. We all love you.

A Race!

2011-11-06T17:16:00.001+02:00

I used to say I would never run. I also said I would never wake up early to exercise! Well all that changed last year. After walking the 10 km race at the Soweto Marathon, I saw an announcement for the Gaborone Marathon at which there was also a 10 km race (but only a run). Long story short, I was talked into training to run it. I realized that anyone can run if you run slow enough (my run is definitely more of a jog ;) I also realized that in Botswana the only time when it was cool enough to run outdoors in the summer was just after the sun rose (before it had time to heat up the day). So crazily I began to get up early to train. Things were going well until a few weeks before the marathon when it was canceled! Of course, this was after I had already paid my 50 pula (around $8) and I was told that there would be no refunds - just an entry into next year's race. Anyway it was sad and I decided I would have to try again. Upon moving to Cape Town, I began running again, this time at more normal hours (after work) as it is not as hot here! I decided to RUN the 10 km race in the Soweto Marathon. This year on November 6th I did just that! I had one goal - to run the entire thing (not to walk any parts of the race). Despite several large hills, I managed to achieve my goal and to run the 10 km in 1 hr and 10 min which I was happy with (you might remember that I walked it in 1 hr and 35 min, so I really don't run much faster than I walk, but still ;)

My friends Jacquie and Shikata drove down from Botswana to meet up with me and run the race as well. We made a nice weekend out of it. We stayed in the same B+B in Soweto as we did last year. We went to the Apartheid Museum and though I had been once almost 2 years ago, I still managed to learn a ton. We also went to Nelson Mandela's house in Soweto. Of course, he did not actually live there very long before being sent to Robbin Island but Winnie Mandela and his children lived there while he was in prison. Unfortunately it was burned at one point so there is only one original table (it had been leant to someone else and they got it back afterwards). The house has a random collection of various citations and awards that the Mandelas have received over the years. Including "the key" to the city of Newark! There is also the tree in the backyard under which all of the Mandela's children and grandchildren's umbilical cords have been buried. Jacquie and Shikata dropped me off in Pretoria for a week of working that side, before heading back to Botswana. So we stopped at the Union Buildings as well. The Union Buildings were designed by Sir Herbert Baker in 1910 and were the site of many marches and protests over the years. Today it houses the offices of the Presidency and Presidents (including Nelson Mandela, of course) are inaugurated at the Union Buildings.

This is Jacaranda season. Pretoria is known for it's Jacarandas, in fact it is called Jacaranda City because there are so many lining all the streets that the whole city looks purple during this time of year. It is quite pretty.

The race was followed by a week in the Northwest Province. In addition, to our regular visits to the clinics, Carolin (one of the South to South nurses) and I conducted a two day training for nurses in the Province. We were supposed to have 11 people, but due to staff shortages we ended up with only 6. It was unbearably hot (40C/104F) and the room we were in had no fan or anything! It was a challenge for the participants to stay awake, however we did manage to get them to do some group work on cases to stay awake. It is really incredible the conditions under which nurses here work and a true testament to their commitment to their patients!

Here is a slideshow of the week's events:

Bo-Kaap

2011-10-24T22:00:00.000+02:00

Believe it or not, there is Groupon South Africa! When I saw a coupon for a cooking tour on there, I knew it was meant to be. Who doesn't want to learn how to make Cape Malay Curry, Chili Bites, Samosas, and Roti? So on Saturday I headed to Bo-Kaap, a 15 min walk from my house. The neighborhood is full of colorful houses and home to much of the Cape Malay population in Cape Town. The Cape Malay community are descendants of slaves brought over from Indonesia, Malaysia, other parts of Asia, and the Middle East by the Dutch East India Company in the 16th and 17th centuries. Cape Malay is actually not a correct term as many are not from Malaysia, but they were all clumped together by the Dutch. Many practice Islam and the Bo-Kaap area has many mosques today (though they were originally not allowed to practice their own religion, they were able to maintain it).

We (a group of 16 South Africans and me) were met by Zainie at the Bo-Kaap museum (which has a small exhibit on the history of the area). She gave us a brief orientation to the area and some of the history and then took us to the famous Atlas spice shop which has supplied the community with the essential spices for years. She pointed out some the essentials and then we walked to her house a few blocks away. Walking down the street we were greeted by the aroma of delicious smelling curry and knew we were headed in the right direction (she had already spent the morning preparing chicken curry since the group was so big).

We started by making Rotis. Basically flour, water and oil but then after they have "risen" a bit you roll them out in a special way, spread butter on them, roll them back up, freeze them so the butter sets, roll them out again and then fry them! Quite a process, but it results in buttery goodness. While the rotis were rising we start on the chicken curry, but she instructed me, and the other vegetarian, on how to make a butternut squash, carrot, lentil curry that was delicous! Then we made our own samosas, quite fun to fold. And chili bites as appetizers. After 2.5 hours of cooking we sat down to a spectacular meal. At the end we each got a recipie book and a starter package of spices to go home and try for ourselves! Looking forward to attempting it one day soon ;)

Here is a slideshow of photos (have to go to the actual blog for the slideshow as always ;)
The first few pictures are of a movie set next to my house. No photos were allowed when they were actually shooting, but they stopped filming on Friday. On Saturday morning as I made way to Bo-Kaap, I noticed that the set was still there. So if you every see The Great Britian Story you might recognize something from these photos and will know that it was filmed next door to my apartment complex ;)

Hikes

2011-10-18T22:44:00.000+02:00

20 years ago if you asked me to go on a hike, I complained, had to be bribed with M+Ms, and "hated" it! I am also NOT a morning person. So many would be surprised to learn that I agreed to wake up at 6 am last Sunday for a hike! My how things change, as I now love hiking ;) But really, who could refuse a hike with views like this one?

When people think of Cape Town, they often think of Table Mountain, but Table Mountain is actually one mountain in a whole mountain range and there are tons of awesome hikes. One of the participants, Allan, who attended the training that I conducted last week, asked me if I wanted to join him and a few of his friends for a hike. I would have preferred to start a bit later in the day, but people here like to get up early. We drove to Noordhoek, a suburb of Cape Town and ended up hiking for 4 hours. It was a beautiful day and we were joined by two gorgeous and super well behaved dogs. We went along the trail at Silvermine and ended up in Elephant's Eye cave (which is where the picture above was taken). From there you can look out on the Southern Suburbs of Cape Town. Interestingly it is a great view of Pollsmoor Prison (an infamous high security prison in South Africa) which is situated right next to an extremely posh golf course community! How is that for interesting zoning?

Here is a slideshow of the day:

The previous Sunday I also went hiking. This time up Table Mountain. I have been up Table Mountain a few times, but always on the cable car. It was probably not the best idea to try to hike it the day after fasting for Yom Kippur when it was 90+ degrees out, but I made it. I went with Bev (who I met at a Rosh Hashanah dinner) and her friend Jon. It was nice that I got to attend services this year for Rosh Hashanah and Yom Kippur, though it did make me miss B'nai Keshet and it's fabulous co-presidents even more ;) We went up the most direct route which is basically straight up and it is in the sun the whole way. It was a rough hike and next time I will make sure to drink water and eat the day before ;) But it was worth the sense of accomplishment at the end!

Here are some photos from that day:

Heritage

2011-10-06T22:54:00.001+02:00

September 24th was Heritage Day in South Africa. September 24 used to be Shaka Day in KwaZulu-Natal (a large province along the Eastern coast of South Africa) in commemoration of King Shaka (an influential Zulu king). After the end of apartheid it was not initially included in the public holidays bill, but the Inkatha Freedom Party, a political party representing a lot of Zulus, objected to the bill without the Sept 24th holiday. As a result, a compromise was reached and the holiday was renamed "Heritage Day" and made into a public holiday in 1996. The holiday is intended to celebrate "the rainbow nation" and all the diverse cultures which are represented in SA. A nice idea. Recently many people have started calling it National Braai Day since Braaing (or BBQing as it is called in the US) is certainly a part of the culture here. Everyone loves to have a Braai.

What it met for me was that all the government run museums in the city were free for the week! So I took advantage and decided to explore a few of those which are literally in my front yard. I went to the South African Museum which reminded me of the National Museum of history in NY (large skeletons of whale, mineral collection, etc.) I also visited the South African National Gallery which had some interesting art. And the Castle of Good Hope which is the oldest building in South Africa. It was built on behalf of the Dutch from 1666 to 1679. It was complete with torture chambers and a posh palace for the governor which has turned into a museum of artwork and antiques. Imagining some of the awful things that I am sure went on in the Castle was a sobering experience.

Some photos from the day....

Education?

2011-09-24T22:56:00.000+02:00

I have been volunteering with a group called Equal Education here in Cape Town. They are advocating for improvements in the education system in South Africa. During the Apartheid era, education of Blacks was called Bantu education and was specifically designed as a separate and unequal system (interesting that this system was implemented just as the similar system in the US was being deconstructed). I think Bantu Education is pretty well summed up with this quote from Hendrik Verwoerd (The Minister of Native Affairs in 1953 when the policy too affect):

"There is no place for [the Bantu] in the European community above the level of certain forms of labour ... What is the use of teaching the Bantu child mathematics when it cannot use it in practice? That is quite absurd. Education must train people in accordance with their opportunities in life, according to the sphere in which they live."

Obviously, this system is hard to undue. After 4 decades of inferior education, the damage cannot be undone overnight. Still most of the current teachers in Black schools, (although they are not officially segregated anymore, they are largely segregated by where people live), were educated in the Bantu education system and are not really qualified to teach the new education curriculum. The schools are overcrowded, many lack proper sanitation facilities, and 92% of South African public schools do NOT have libraries! Equal Education is an advocacy group that "advocates for quality and equality in the South African education system and engages in evidence-based activism for improving the nation's schools." You can read more about them here: http://www.equaleducation.org.za/what_is_EE

One of their many projects is to work with schools to create libraries. Most of the schools have a space called a library, but they don't have books, librarians, computers, etc. So Equal Education collects books and donations and has already opened about 14 libraries. I have volunteered with them a few Saturdays in the past few weeks to sort, cover (the books are mostly paperback so they are covered in clear contact paper to increase their lifetime), and catalog books. Today was the opening of a library in Khayelitsha (the largest Township in Cape Town - 1 Million people!) It is at Matthew Goniwe Memorial High School. The opening was quite moving. The program started with a learner performing a poem about the principal and her work to improve the school.

Then the principal spoke about how the school had gone from being in the news for the wrong reasons (two separate stabbings of students in 2005 and 2006) and now was classified as the best high school in Khayleitsha! She spoke about her efforts to create a book club of teachers and students (with the help of Equal Education and a local bookstore). She was told to select 15 students, but had 25 who were interested and qualified after visiting only 5 classes in the school and had managed to get all of them included. And how she and all the learners were so excited about the library.

Next 4 learners performed a scene from a book they had read and a small group sang some beautiful songs (not the best quality video recordings, sorry).

And then the ribbon was cut and the library officially opened. The learners quickly filled the room and went right to the books. They began taking them off the shelves, reading them, and sharing lines with each other. It was clear that the library will be well used and a much needed resource in the school.

Row of outhouses

After leaving, I drove around the township a little bit. Rows of shacks, poorly maintained roads, lines of outhouses, crisscrossing electricity wires (as there are many illegal electricity connections), and trash abound. I can only begin to imagine all of the struggles that students from this environment face everyday! But I hope that having a library, and the ability to take books home, will at least make a small improvement in their lives.

A slideshow with some other photos from the day:

Trainings, Wine Tasting, Visitors, oh MY!

2011-09-18T23:26:00.000+02:00

Sunset over Table Mountain

It has been a busy few weeks! The first weekend in September there was a festival called Franschhoek Uncorked in the winelands (Franschhoek is the name of one of the wine routes near Cape Town). Marina, a previous South to South epidemiologist who now works for a PEPFAR funded project in Pretoria, invited me to join her and two of her friends for the festival. We hired a driver (so no one had to drive home after a whole day of wine tasting) and toured 5 different wine estates. Each estate had a different theme for the weekend, with music, food, and of course wine tasting. We had a lot of fun.

Here we are with the Champagne (well they can't actually call it that, since it's not made in France) that Obama had at his inauguration!

With the "mariachi band" at one of the wineries which was having a Spanish themed day. (Of course none of these men were actually latin and my rusty Spanish was better than theirs but it they sang and played well.....)

The first week in September I helped conduct two trainings. The first part of the week I was at a training at Tygerberg Hospital. South to South conducts these trainings once a month. Doctors (and a few nurses) come from all over South Africa to spend 5 days learning about pediatric HIV. They purposely keep the training groups small (no more than 12) to encourage participation from all group members. Many of the trainings are taught by South to South staff and then other specialists are brought in from Tygerberg Hospital to contribute as well. In addition, the participants get to shadow in the children's HIV clinic at Tygerberg and spend time on the pediatric ward at Brooklyn Chest Hospital (where children with complicated tuberculosis infections are admitted). Since it was my first training, I spent a lot of the time observing and taught one lecture on the HIV medications. It was nice to have such a participatory group, makes teaching so much more interesting! On Thursday and Friday, South to South was also conducting another training for one of our collaborating agencies so I went to help with that. We had 35 doctors, nurses, pharmacists, and pharmacy assistants at the two day basic pediatric HIV training. We were able to split them in two groups, and I got to work with the nurses. We had many lively discussions and though it was brief, I think they were able to get comfortable with the basics.

Along Chapman's Peak Drive

Most excitingly my first visitors in my new apartment arrived! My first visitor in Cape Town was actually my college roommate, Kerry. She was traveling around South Africa and visited Cape Town shortly after I arrived. We spent two days talking and catching up, as we had not seen each other in a few years. Unbelievably, we did not take any pictures together! Crazy, but I think we were so busy talking that it never occurred to us. Last week my brother, Aaron, and his girlfriend, Jen, came to visit and Aaron made sure that there was plenty of photo documentation! He took more than 1,000 pictures in 5 days!!! It was great to see them and to get to show them Cape Town. We went to Cape of Good Hope (the most Southwesterly tip of Africa), drove Chapman's Peak (beautiful costal views), took the Cable Car up Table Mountain, and ate lots of good food. They got to go wine tasting and see Robben Island while I was at work. We also discovered some new things, most importantly a Saturday market at The Old Biscuit Mill in Woodstock (a neighborhood in Cape Town) which sells amazing prepared foods, cheeses, homemade wines, paella, etc, etc. I even went back this weekend and think I will make it a Saturday morning tradition of sorts ;)

Me and Jen on the beach at Camps Bay for sunset!

Here is a slideshow of some of the best photos taken by Aaron (and a few by me and Jen) - hard to pic out of a 1000, but don't worry there are less than 60....

Moretele

2011-08-28T18:40:00.000+02:00

So the big question is what I am actually doing at work? Well, last week I really got to find out! It was my first "implementation week." Basically South to South is working with the departments of health in the different provinces to help them improve their pediatric HIV care. Since things in the Western Cape (the province that Cape Town is in) are already decent, most of our work is in other provinces (there are 9 in the country - sort of a similar concept to states in the US). Right now we are working in the Northwest Province in a sub-district called Moretele (it is blue thumbtack below - you may have to zoom out a lot to get prospective, if it doesn't stay zoomed out)

View Moretele in a larger map

Moretele is about 1-2 hours from Pretoria depending on where in the area you are going and how much rain there has been (since many of the roads are dirt roads, when it rains a lot there is a bit of a problem getting around. Luckily it is dry season right now ;) There are 26 clinics in the area and we are focusing on 10 (as requested by the department of health). Only 4 of them currently supply ARVs to patients (and 2 just started this month) the rest of the patients who are HIV positive must travel to one of those clinics to get care, which is an improvement since they used to have to travel to the nearest hospital which is not even in their district. The clinics are pretty far apart considering most people do not have cars, bikes, or donkey carts and public transportation is limited to minibuses....Many of the clinics do not have running water. Most of the clinics have a severe chair shortage so meetings are held either standing up or on the beds in the labor room (when there are no patients in labor). So what we are doing is helping the nurses, lay counselors, and the few doctors and pharmacists develop their skills and comfort in treating pediatric HIV. We are also focusing heavily on PMTCT (Prevention of Mother to Child Transmission) since that is really the only way to stop pediatric HIV. Some of the time is spent mentoring individual health care workers and the other part is helping the clinics put systems in place to improve care.

A typical sign listing the services at the clinic - though most are supplied by nurses only and many patients have to be referred to the hospital for further management which is hours away. There is an ambulance in the area most of the time for emergencies though it can take a long time to arrive (and if it is not a life threatening emergency they have find their own transport, which many of them cannot afford)

On Tuesday, I got to attend the second meeting of the Teen Club in one of the clinics. There were 11 teens (a stark contrast to the 200 who attend Teen Club in Botswana every last Sat of the month). But this is the beginning. The teens got to know each other, elected members to do different tasks, and discussed the importance of confidentiality. I am looking forward to working with the social worker at the clinic to help her develop the Teen Club even further, but it is off to a great start. The kids were really engaged and clearly appreciated being able to attend.

The road to one of the clinics

South to South (S2S) has created registers (basically like patient logs, where healthcare workers enter information about the patients and columns like "mother on HAART y/n" prompt the healthcare worker to ask certain questions and send certain tests). These have helped to improve the numbers of women who are receiving ARVs when they are pregnant and in labor. But we realized that some of the health care workers do not really understand why they are doing certain things - they are just following protocols. This is generally good except that without understanding the reasoning behind the protocols, they are often missing things. So on Wednesday one of the S2S nurses and I sat with all the nurses in one of the clinics and explained the reasoning behind some of the protocols to them. It was so nice seeing the lightbulbs go on in many of their heads.

I will be going to this district 1-2 weeks each month for the next 6 months and then we may expand to other districts depending on how things are going in Moretele. In between traveling weeks, I will work on projects identified while there (this week, improving their adherence sheets, collecting resources for the teen club, and improving the registers). And also conducting week long trainings at Tygerberg Hospital at the University of Stellenbosch (first one for me is Sept 5-9).

One of the clinics we visited is trying to make the outside look nice so all the workers at the clinic each brought a plant and they were planting and watering when we arrived.

On one of the days we visited a business of local women called the Heartfelt Project during the lunch break. It was started by a woman named Martha after her son was wrongly accused, imprisoned and died in prison. She lost all of her money to a corrupt lawyer who had promised to get him out. She had worked for 20 years for a family in Pretoria and their daughter, Julie, helped her start the business. Now they have 10 employees and create all sorts of hand sewn felt designs. If anyone is getting married (or having another occasion to party) and needs nice party favors, consider ordering some from them they are great and the profits go to the women and also to support a local community health project. .....www.theheartfeltproject.com is where you can read more about them and place orders.
They will even ship all over the world with enough time ;)

Here are some of the designs before being sewn and stuffed.

Hope everyone reading this on the East Coast is managing to stay dry and get back your power! Stay Safe!

Larry Joe

2011-08-19T20:27:00.000+02:00

A few days ago I was invited to hear a guy called Larry Joe perform at a local synagogue. I had never heard of him and so I googled him before going and thought he sounded good. Also I thought he must have an interesting story since the songs online were recorded in prison! But beyond that, I had no idea what to expect and I was truly inspired by him and his story.

He was introduced by Aron Turset-Swartz (a founding and now former member of the band Freshlyground. Aron said that on World AIDS Day (Dec 1) in 2008 Freshlyground was asked to perform at a small concert in Douglas, South Africa (in the middle of the country). As the sound equipment was being set up a man came on stage and performed two songs which both got a great reception from the audience. Aron remembered being struck by how great the guy sounded and he asked him who he was and where he was from. "I'm Larry Joe from the Douglas Correctional Center," he said pointing to the side of the stage where 4 armed guards were waiting to take him back to prison. To make a long story short, after the concert Aron developed a relationship with Larry and eventually ended up becoming his producer and helping him to record his first CD.

Then Larry took the stage and began to play his guitar and sing his original songs in 5 different languages! I thought he was really good. In between songs he told his story. Basically, when he was in his early 20s he broke into a few houses in Kimberley, South Africa. When he heard the police were looking for him, he ran away to Cape Town. He had learned how to play a few chords of guitar from his father and liked to sing. He begged for money until he had enough to buy a guitar and then began to sing on street corners around Cape Town. He did this for 7 years and got better as he went, always singing covers. One day he had a dream that he was playing in Madison Square Garden and he decided that he could not really pursue a music career until he served time for what he did. So he returned to Kimberley and turned himself into the police. He was sentenced to 5 years in prison. While in prison he used the time to improve his musical skills. He began to write his own music for the first time and wrote over 40 songs in 5 different languages. He only really speaks English and Afrikaans, but he had guards and other inmates translate some songs into Xhosa, Spanish, and Portuguese for him. In addition, he says he read every book in the prison library and used those to inspire his songs in other languages.

Here he is playing with Aron backing him up on a wooden box as a drum

The prison was incredibly accommodating of his desire to practice and play music, allowing him to play in his cell, asking him to perform at that World AIDS Day Concert, and eventually letting Aron bring in recording equipment so that he could record his first CD from inside a cell in the prison. They were apparently so accommodating because they want to aid prisoner rehabilitation and they saw this as a great opportunity for Larry.
He was released on parole on December 13, 2010 and his CD was released that day as well. Now he goes around to schools, prisons, and other community organizations to sing and tell his story in the hopes that he can inspire young people to follow their dreams. Definitely an inspirational story!
Here is a link to a video about him so you can hear him sing
http://www.youtube.com/watch?v=EQgXj1s1sQ4&feature=related.
If it doesn't work just go to youtube and search for Larry Joe.

On a totally unrelated note, for your entertainment purposes, I am going to include the following picture of me and my bosses.

Elke (Pediatric Unit Manager), Liezl (South to South Clinical Director) and Me

What is so great about being in pediatrics is that pediatricians are generally fun. Elke and I are both new to South to South (though Elke started 2 months ago). So at our staff meeting, Liezl welcomed us into the organization by giving us each a pair of eyeglasses made from wire. This is because now we are joining South to South and their vision for better pediatric care for children. Each previous staff member has also gotten to go through this ritual. We then got to decorate them with ribbon and beads (you can't really see the beads which form the side of the glasses, but trust me they are there ;)

Slideshow reposted

2011-08-17T18:53:00.000+02:00

Apparently there were problems viewing the slideshow on the last post. I hope this one will work better....

If still not working, click on this link to view https://picasaweb.google.com/109170280186909692299/August142011?authkey=Gv1sRgCIP3oJeSv6LB2gE

Settling in

2011-08-16T23:01:00.000+02:00

Now that I have been in Cape Town for 2.5 weeks, I am beginning to feel a bit more settled. I am working in Bellville which is one of the Northern Suburbs of Cape Town (30 km and about a 30 min drive from the city center). It felt too suburban and too segregated for me to live there, so I decided to live in Cape Town itself. But since choosing an apartment over the internet is hard anywhere, and esp difficult when you don't really know the city very well, I decided to wait until I arrived to find a place. For the first two weeks, my work arranged for me to stay in Bellville in a self-catering apartment which was a 10 min walk to work and 10 min walk (in the other direction) to a shopping center. So after a 36 hour trip (through Dubai), I was met at the airport by my super nice co-worker who took me to the local Pick and Pay (grocery store) and to the apartment. The next day I rented a car (my first time driving a manual alone, more on that later) and began apartment hunting. In 2 days I must have looked at 20 apartments (some in Blouberg - along the beach and the rest in the city). I decided on a place in center city right across from Company Gardens. The big blue thumb tack below marks the spot of my building (this map is in my grandfather's honor), if you click on the map you can zoom in and out to get a better sense of where it is....

View St. Martini Gardens in a larger map

It is completely furnished which saves me a lot of hassle. Parking is under the building and it is walking distance to tons of great restaurants, shopping, a lovely public garden, etc. I got a 2 bedroom apartment so there is plenty of room for visitors ;)

A slideshow of the first 2 weeks (if you are reading this on email you have to go to the blog to see the slideshow)....

Which brings me to the car! I did not know how to drive a stick shift before I got to Botswana but last year I learned under the tutelage of Gelane and Bri on our many trips for our outreach evaluation. And after our trip to Swazi/St. Lucia, I was feeling pretty okay with stick. Only a few small problems here: HILLS (and very steep ones), lots more people, stop and go traffic.....all these things make driving a stick shift much harder, esp when you learned in a flat, sparsely populated country. So let's just say that driving stick when I rented a car was interesting and I was thinking that my life would be simpler with an automatic car. However those are hard to come by, more expensive, harder to get fixed and harder to sell. As a result I ended up with a Nisaan Micra (ever hear of that one?) I think it looks like a bug, but it is nice and small (good for parking around here), supposedly light on fuel (it better be considering it cost me the equivalent of $45 for 3/4 of a tank!!!!), and relatively peppy on the highway considering it only has a 1.4L engine! So far so good, I am getting better on the hills and each day feel slightly more comfortable driving stick....though I still don't understand the appeal when automatics are so easy.

So far work has been a lot of logistics as well. Familiarizing myself with guidelines, protocols, training manuals etc. They have developed a great pediatric toolkit to help healthcare providers when they are treating children with HIV. It was developed for South Africa but now is being changed to be more generally based on the WHO guidelines so it can be used in many other countries, so I helped with that process. All my colleagues are very nice and friendly and it seems we will make a good team. My first mentoring trip is next week, so I will have a much better sense of things by the end of the month.

One thing I have seen here are the incredible disparities, which I am sure I will see even more of when we go up to the Northwest Province where we are doing the mentoring. The city is very modern, has good infrastructure, plenty of pretty buildings, and tourist attractions. However, though apartheid ended 17 years ago, there are many lasting effects still present today. Residential areas are still incredibly segregated. In fact, when I called real estate people looking for houses, I talked to one agent, over the phone, who told me "that area is not for you." I asked him what he meant by that and he said "Trust me, I try to match the right people with the right houses." I had never met the guy, but I am guessing that he could tell I was American by my accent and probably just assumed I was white based on that. I never met him, so I was unable to investigate his reasoning any further.

The inequities are everywhere if you pay even a little bit of attention. When I was moving into my apartment, I had several boxes of things shipped from Botswana to Cape Town. They arrived bundled together in a giant cardboard box. As we were unpacking the giant box in the truck in front of my building, the guard for the building was keeping watch. When we had all the smaller boxes in the apartment, he asked me if he could have the giant cardboard box. Of course, I said yes and then just because I was curious I asked what he planned to do with it. "Take it to Khayelitsha [the largest township in Cape Town] and use it to cover my shack since it is so cold," he told me. Here I was unloading boxes of clothes, blankets, knick knacks, etc and this guy was trying to get some extra insulation for his shack. Having driven past Khayelitsha and other townships, I have seen the condition of housing there, but I naively assumed that most of the people living in shacks were some of the 25% of the population who are unemployed (a shocking number that I read in the paper this morning). In fact here was the guy who is working 12 hours a day, 6 days a week as a guard of a big apartment complex and he too is living in a shack. The disparities here are even greater than in Botswana where, though there is definitely extreme poverty, people who are working can generally afford something more substantial than a shack. Highlights once again how far there is to go to overcome decades of forced segregation and oppression and how fortunate I am.

Flashback: Bushfire and St. Lucia

2011-08-09T20:00:00.000+02:00

Enjoying the music at Bushfire

Bushfire is an annual music festival in May Swaziland - 3 days of live performances from all over the world (though most performers were from Africa). Gelane, Premal and I missed it in 2010 so we had been planning to attend in 2011 for some time. Then realizing that there was a Botswana holiday the same week, we decided to make a week of it and explore the Eastern coast of South Africa with Bri joining us there. We got off on a bit of a bad start. We drove from Gaborone to Pretoria in Gelane's car and then realized that the radiator was leaking. We took the car to a Honda dealer and they said the radiator needed to be completely replaced.....We spent several hours in the Honda dealer (during which I finished the handwarmers I had been making for Gelane)...

Gelane testing out the new hand warmers and praying that they would be able to find a radiator in the area!

Unfortunately they were not able to find the radiator in the area and told us that the car could not be fixed until Tuesday (it was Friday and bushfire was Friday-Sunday in Swaziland which was still a 5 hour drive away!) So we went into planning mode and to make a long story short - headed off in a rented Nissan Hardbody truck (with manual transmission)! We needed such a big car since we had so much stuff (below is Premal in the rental agency with all our stuff....)

We finally arrived in Swaziland at night and managed to put up our tent in the dark (Premal got really into hammering in the stakes - below) before heading out to experience the music.

For 3 nights and 2 days, we were treated to some amazing performances. We camped right next to the area where the stages were and it was great to be able to come and go as we pleased.

Here is Gelane in the midst of the crowd in front of the stage

It was gorgeous during the days and pretty darn cold at night, but thanks to Liz and Jon's awesome tent and camping equipment we managed to stay pretty warm.

Oliver Mtukudzi was definitely our favorite. He is in his 60s and still was jumping around the stage and has an amazing voice!

There was one artist from Botswana, Shanti-Lo, who we also really enjoyed.

When the concert finished we drove through Swaziland (it is a tiny land locked country surrounded by South Africa). We stopped at the Swazi Candle factory where we saw intricate candles of all kinds (from elephants to birds to larger circular creations - these people were talented with wax) being made.

We watched this entire rhino be created and it only took about 10 minutes!

Next stop was St. Lucia - no not the island in the Caribbean! There is a beach town along the Eastern Coast of South Africa called St. Lucia. It was a very sleepy beach town (esp. because it was not high season). Which meant we had a gorgeous beach to ourselves and plenty of room for the requisite jump shots ;)

We even went snorkeling one day though the water was extremely cold and the waves were pretty rough. After freezing a bit and getting bashed by the waves, Gelane and Premal spotted a small tidal pool and decided to try it....

The town is basically in the iSimangaliso Wetlands Park which provided for some amazing views and landscapes as well as excellent animal spotting on our self-drive safaris. We saw rhino, buffalo, giant kudu, and then on a boat cruise we were super close to Crocs and hippos!

Here are some photos from the boat cruise

Bri, Gelane, and I even got to go scuba diving in Sodwana Bay which is bit further North of St. Lucia and as extremely clear waters with tons of beautiful fish.

All in all an amazing last trip from Bots!

Flashback: My Last Teen Club :(

2011-08-06T16:33:00.000+02:00

When teens are asked what topics they want to learn about at Teen Club, sexual issues are often first on the list. There are numerous myths and misconceptions all over the world when it comes to sex. This is especially true in a conservative country like Botswana where teachers, caregivers, and even some healthcare workers are reluctant to talk openly with teenagers, deeming this topic inappropriate and unnecessary for adolescents. I was asked to play an active role in planning a Teen Club about sex so that the Teen Club staff could make sure that all the information which was presented was medically correct. The planning sessions became a bit tense in the weeks leading up to the event, as some of the clinic staff did not feel that it was appropriate to have such a discussion with the teens. However, after much debate it was acknowledged that this is a critical subject for all teens and that Teen Club is probably they only place they are going to get to have their questions answered in an open, honest and medically correct way.

In preparation for this discussion/forum, teens were notified a month earlier that the June Teen Club would be about sex, giving them enough time and opportunity to prepare questions. The team placed a visible box in the clinic for them to write down anonymous questions about sex and sexual health.

On the day of the event, teens were divided into the usual two groups (13-15 and 16-19 year olds). For the younger teens we had 3 stations: playing games; dispelling myths (as you can see me explaining above); and a short discussion on puberty and importance of abstinence. The teens rotated from station to station every 40 minutes. There was concern that that some might not be mature enough for the topics, but once again they surprised us with their maturity, concentration, and engagement with the subject.

During the short discussion on puberty we taught them about the normal changes that the body goes through, as they get older, the importance of abstinence and the need for protection when abstinence is impossible. We also answered many of the questions they had about sexual issues and puberty. During the myths/facts session the teens were given a myth and asked to go to the area of the courtyard corresponding to their feelings about the myth (true, false, or don’t know). We then discussed the answers in detail, dispelling such myths as “two condoms are better than one” (two condoms are NOT better than one!) and “a girl cannot get pregnant if she has sex standing up” (She CAN!) which are two common myths in Botswana.

The older teens had male and female condom demonstrations led by three wonderful volunteers from the Ministry of Health (MOH), who volunteered their time and expertise on a Saturday. Their experience is extensive – they have conducted demonstrations all over Botswana in many different settings from schools to community centers to other public gatherings.

Teens were divided based on gender, in an effort to encourage more open discussion and stimulate questions. Most were eager to share what they thought to be correct information about condoms and their use. The demonstrations certainly stimulated questions ranging from myths of pregnancy and changes the body goes through during puberty to more complex issues such as age of sexual debut and perceived ideas about the roles of a man and a woman in a relationship.

Then all the older teens were brought together and their questions were answered (both those they had placed in the question box and those which they came up with on the spot). Once encouraged these young men and women were eager to take the opportunity to ask and demystify concepts about sex and sexual health. Due to time constraints we were unable to answer every single question and will definitely have to have more sessions on this topic in the future.

All in all, the event went better than the team expected. The teens were serious and mature about discussing the subject, even more so than many adults when placed in similar situations. We felt their appreciation through their enthusiastic participation, eager concentration, and mature disposition.

At the end of the event, the teens surprised us with a dance number and kind words to say goodbye to me and Gelane as it was our last teen club. We both expressed to them how much we had learned from them and how their strength and resilience are truly an inspiration to all.

Transitions

2011-08-05T18:25:00.000+02:00

Gelane, Bri, Premal and I were super sad to say good bye to each other!
I know we will keep in touch, but after 2 years of living, working, traveling together it was really hard to part.

It has been forever since I posted, I know, but I am going to try to get back into it. You might have noticed that the description of my blog has changed (it is now "tales of my life as a pediatrician in Botswana and beyond....") I figured that was easier than setting up a new blog. That is because I have moved to Cape Town, South Africa! The Pediatric AIDS Corps program had 5 years of funding which ended in July 2011. Other sources of funding were sought and the program transitioned to the Global Health Corps this July. It will be very similar to the PAC program, but smaller and will focus on more than just HIV/AIDS. Though it was quite hard to leave Botswana, all the patients at the clinic there, and the friends I have made in the last 2 years, it was time to move on.

I also had to say good bye to Gizmo our cat. He clearly wanted to come along, but loves to be outdoors and I don't think he would have done well in a Cape Town flat.
Luckily Bilen moved in next door and Gizmo moved in with her.
They are both very happy now ;)

I have taken a job with an organization called South to South. It is an NGO that is funded by USAID and is housed at the University of Stellenbosch in Cape Town. The goal is to help South Africa expand their pediatric HIV program. Many healthcare providers are comfortable treating adults with HIV but not children, so our goal is to help them feel comfortable treating children. In addition, the goal is to increase the number of clinics that provide ARVs (medications to treat HIV) so that patients do not have to travel as far to reach the clinics or wait all day to be seen (do to overcrowding at the centers which exist). You can read more about it here if interested www.sun.ac.za/southtosouth.I am the Pediatric Clinical Advisor which means I will be doing training and mentoring of healthcare workers (nurses, doctors, lay counselors, etc). A lot of my time (about 40%) will be spent traveling around the country. Right now we are focusing on a district called Moretele which is in the Northwest Province of South Africa (about 2 hours north of Johannesburg), more on that in a few weeks after I have actual been.

Almost half of my residency class managed to make it to Sonia's wedding!

Sonia and Elliott are officially married

Before moving to South Africa, I was lucky enough to get to spend almost three weeks back in the States with family and friends. I was really lucky that Sonia decided to get married during that time and so I got to attend her beautiful wedding and see a lot of my friends from residency (as well as two delightful new additions to our St. Chris family - Josie and Walter ;)

Josie, beautiful daughter of Meredith and Trevor

Walter, adorable son of Ruth and Robert

I spent lots of quality time with my parents, grandmother, aunts, uncles, and cousins. Definitely the thing I miss the most about being "this side" is time with family and friends who are "that side" but luckily the technological age (skype, internet phones, etc) helps with that a lot.

I will try to post a few flashbacks of my last months in Bots and then will move on to giving you a sense of life in Cape Town. Right now it is a lot of logistics, finding an apartment, buying a car, opening a bank account, etc but photos and details of all those things to come!

Adventures in April

2011-05-15T21:09:00.000+02:00

The last week in April was an time for another adventure. Josanna, Elizabeth, Bilen, and I drove from Gabs to Rustenberg, spent the night at a cute bed and breakfast and had our customary sushi dinner at the Cape Town Fish Market in Rustenberg. The next morning we drove to Joburg arriving with plenty of time to sort out where to leave my car. We ended up giving the car to Jacob a guy who works for a valet service at the joburg airport. They have a business where they pick up cars at the departure terminal, take care of them (including washing them) and return them to the arrival terminal upon your return. They came highly recommended by the owners of the Bed and Breakfast in Rustenberg. Though I was still pretty skeptical of giving my car to a total stranger in a city known for car theft, it worked out! He drove us from the airport to the bus terminal and was there with the car when we came back and it was cleaner than it has been in a long time! Our bus was 1.5 late so we left Joburg at 11:30 pm and arrived in Maputo at 9:30 am the next day after an uneventful bus ride where we were able to sleep a bit. From Maputo we got a ride to Bilene a beach town about 3.5 hr away.
Bilene was a really tranquil place. Not too touristy. We stayed at a place about a 45 min walk from town which was on the lagoon beach. We spent three days relaxing at the beach, snorkeling with sea horses, and hanging out at a great local bar. Chichunga's became our home away from home. Each day we bought fish from women whose husbands had caught it that morning and Chichunga marinated it during the day and cooked it for us that night. It was the best fish I have ever had (as you can see in the pictures, we did not leave any behind).
After 3 days, we rode back to Maputo and met up with Gelane (who had been to Cape Town with plans to run the 1/2 marathon - though those plans were thwarted by shin splints she still had a good time there). Maputo is a much busier city than Gabs, and a lot dirtier. We took tuc tucs around the city, explored an old fort, ate at the fish market, and did a fair amount of shopping. At night we found a great bar/club which had live karaoke and the following night a reggae band. We had a minor run in with the police since we were not carrying our passports on our way to a club! They pulled us over during a random stop (when we happened to have 6 people (including the driver) in a cab which is apparently not allowed, though many more unsafe modes of transport seem to be just fine) and told us that we were supposed to have our passports with us at all times. After much hemming and hawing (I think they were just looking for us to bribe them), they finally agreed to accompany us back to the backpackers where we were staying so we could show them our passports and then they left us alone. There were also several run ins with giant rats everywhere we went, not the best when you are eating!
After another overnight bus ride back to Joburg we drove to the Drakensberg mountains (a mountain range on the border of South Africa and Lesotho). It was gorgeous. We stayed at a great backpackers where there happened to be the "Smoking Dragon's Women's Music Festival"that weekend. 48 hours of music from woman performers. It was great fun though we will have to go back to actually explore the Drakensberg since we didn't get to do any hiking.
Here is the trip in pictures: )

Training, Passover, and Tutoring

2011-05-05T22:59:00.000+02:00

The very appropriate coaster that was on the presenters' table during our training.

The first week of April I was back to Bloemfontein, South Africa to do another training. This time it was an Advanced Pediatric HIV Training. Many of the nurses and doctors who attended had been at the basic training in February. It was quite a challenge to explain concepts of antiviral drugs developing resistance to a group of mostly nurses who do not really have the background to understand it (resistance is a very complex topic even for specialists). But we managed to make it a bit fun by having the participants act out the parts of virus and drugs to visually demonstrate. Nevertheless many of the participants got to catch up on their sleep during the training, though we got a lot of positive feedback at the end and people did do better on the post test than they had on the pretest.

After a week in Bloemfontein, I returned to Botswana and got to celebrate another passover in Botswana. This time Liz and Jon hosted a seder. We could not find any matzoh this year (though there was some last year, I am not sure what happened). So Liz actually made her own matzoh!! And then she even crushed it up to make matzoh meal and matzoh balls which were darn good!

Jon was a very entertaining seder leader

Gelane throughly enjoyed her first seder and first matzoh balls!

We had a lot of vegetarian dishes and I made a really good flourless chocolate cake (thanks to Mom for bringing me Scharfenberger chocolate which totally made it).

We even had Leonard (one of the Infectious Disease doctor's almost 2 year old son) to find the afikomen. (He lost his pants during an accidentally spillage earlier in the evening and was more interested in the wire bowl he found than in bargaining for something in return for the afikomen ;) It was great to be able to celebrate with friends, though I did miss the crazy Scherzer/Reisman seders!

During April I also did a lot of tutoring (I was trying to teach multiplication to K.N. above). We started a tutoring program for patients in our clinic as many of them are doing poorly in school (a combination of being sick a lot, missing school frequently for routine doctors visits, and developmental delay can happen from HIV itself - especially for those patients who were started on treatment later in life.) We have recruited volunteer tutors from University of Botswana, among other places, and are now able to offer tutoring every day and on Saturdays. I spent a few Saturdays in April trying to remember how to do calculus, explaining long division, and learning the capitals of African countries.

Yoga, Jazz, and Family

2011-04-20T23:12:00.001+02:00

The gorgeous coast along the Garden Route

The kids who guided us to the elusive eye

The last 2 weeks of March were quite “busy” with vacation. It started with a weekend yoga retreat. I have luckily been able to continue my yoga practice here in Botswana, actually going a lot more than I did in the States. I have a great local teacher and the classes are smaller so there is a lot of personal attention. My yoga teacher’s teacher did the yoga retreat. It was held in Groot Marico, which is a small town in South Africa about 2 hours from here. The setting was ideal, a small retreat center in the middle of nowhere with no cell phone reception, delicious vegetarian meals and nice cottages. Yoga was conducted in an octagon shaped building and as our faces were inches from the ground she mentioned that the floor was made of a cow dung/mud mixture! Wish I hadn’t known that part of it, but it did not smell and was coated with some kind of oil to keep it together….The theme of the weekend was "the elements," which meant exploring the parts of us that are Earth, Fire, Water, Air and Space. I was only around for the first 3 elements since the retreat was three days and we only attended for two. Exploring the element of Earth meant collecting piles of dirt and staring at it for 15 mins, then spreading the dirt out and staring at it again for 15 min and then putting it back in a pile and seeing how we felt about it now that it was back in pile. We then discussed how everyone felt about the dirt and what the earth element meant to us. While I found the idea of the elements interesting and attempting to try to balance them in each of us is a very important and noble goal, staring at dirt, moving water, still water, candles, fire, etc took a lot of patience on my part, which was also a good exercise ;) The yoga was great, again it was a small group so we got a lot of personal attention. We also took a trip to "The Eye" a crystal clear spring near the retreat place, it was quite an adventure to find as it is tucked into the brush along a dirt road (luckily we ran into those children above who pointed us in the right direction). It was raining and cold, but that did not stop us from zip-lining and jumping into the nice cold water ;)

On Sunday I left the retreat by way of a packed combi (minivans used for public transport around South Africa) to travel to Johannesburg and meet my parents who had arrived a few days earlier. The following day we flew to George along the Southern coast of South Africa, rented a car and began to drive the Garden Route.

The Garden Route is the stretch of coastline between Port Elizabeth and Cape Town. It is a gorgeous drive filled with amazing mountain passes, beautiful beaches, and lots of good fish dinners (something I never get in Botswana)! We spent the first two nights at an amazing B+B in Plettenberg Bay. The owner was an amazing cook and the location was amazing. While there we went to the Tsitsikama National Park and hiked to Storm's River Mouth and part of the way to the waterfall. I even convinced my dad to go zip-lining!

On the bridge at the Storms River Mouth

Along the way to the waterfall (we did not have time for the whole hike but the views were breathtaking)

We then drove on Route 62 which is the part of road that weaves in a out of the mountains on some amazing passes. We spent one night at a lodge in the town of Oudtshoorn that was on an ostrich farm and even collected a few ostrich feathers.

Eric the Farmer

Between Oudtshoorn and Swellendam was the famous Ronnie's Sex Shop. It is a bar/restaurant in literally the middle of nowhere that started as a joke and has now becoming a famous stop along the route. Had to get the classic photo of Dad on the disintegrating tractor in front.

A photo opportunity in one of the mountain pass

We arrived in Cape Town on Friday in time for the Cape Town International Jazz Festival which just so happened to be the weekend my parents decided to visit (what great timing). We saw some amazing performances, among them: Hugh Masekela, Earth Wind and Fire and even my friend Matt who was playing with Citie a guitar player from Botswana (the first Botswana artist to perform at the Jazz Festival).

Hugh Masekela (sorry no matter what I do this picture won't rotate, so you will just have to turn your head ;)

Citie on guitar and Matt on sax

We spent four full days in Cape Town exploring. From taking the cable car up Table Mountain to listening to a concert in The Botanical Gardens to eating amazing food it was an awesome time in a great city.

Dad smelling the flowers at the section of the Botanical Gardens designed for blind people (all the plants had powerful smells and signs about them were translated into Braille as well.)

The Philharmonic performed to a packed crowd of serious picnickers (these people were really hard core about the picnicking right down to the stakes which held wine glasses!)

My parents and their friends Richard and Bobbie Polton (who joined us in Cape Town) and were able to find some nice recycled art of their own with the master artists

Mom with a lion made of wire and beads at the Streetwires store (a place that has hired some the local artists who make all kinds of objects out of recycled cans, wires, beads, etc). We purchased quite a number of recycled designs from local artists at a art fair we happened upon as you can see above.

He looks like a professional, eh?
There are tons more pictures and stories, but I wanted to get this up before the next adventure (which starts tomorrow ;) Happy Passover and Easter to all (stories from this year's passover to follow ;)

March

2011-03-13T22:28:00.000+02:00

Wow has it really been a month since my last post? Yikes time is flying....
Well the end of February brought another excellent teen club. We started the day off with two inspirational speakers, one is a judge in Botswana (one of the first female judges) and the other a radio DJ. Interesting combination, but they both talked about leadership and what makes a good leader. Both had great messages about having good self esetem and the confindence you can do things because you can't be a good leader without beliving in yourself first. The teens were very responsive to the messages and asked some good questions. Then we took the older teens (16-19 years) to the pool. Seeing as Botswana is a land locked country that is largely a desert, there are very few opportunities for the kids to learn to swim. Only about half were interested in trying (all in the shallow pool at the Univeristy of Botswana) and the other half played group games with water balloons. It was a lot of fun and since it was really hot outside, everyone was happy to get wet!

Bloemfontein from the air

The first week in March I went to Bloemfontein, South Africa to conduct a basic Pediatric HIV training. There were 31 health professionals at the training, mostly nurses, from all over the Free State (one of the provinces in South Africa which Bloemfontein is the capital of). We taught them about pediatric HIV management. Many are already taking care of HIV positive patients but some of the nuances of managing children with HIV (like disclosing their status to them) were new to them. The training was a week long and well received. There was not much to do in Bloemfontein during the hours we were not conducting the training so I spent a lot of time at the "waterfront" mall. The water is a man-made pond with a water fountain (or "water mountain" as my boss's 2 year old son calls it) in it, but at least there were some decent restaurants.

The "water mountain" at Waterfront Mall

Last week I was back in Gaborone working at the clinic. On Tuesday night we celebrated International Women's Day by attending an event to raise money for an organization set up to fight abuse against women. Unfortunately most of the speakers were not very motivating, just talked about themselves. But there were a few performances including one by Shanti-Lo (a stunningly talented transgender singer) who is becoming very popular in Botswana despite the country's conservative nature. Hopefully the fact that they chose him to be the closing act is a sign of the possibility that there is improving equality and openness in the society as a whole, slowly but still....

The Elusive Black Rhino

2011-02-13T21:40:00.000+02:00

Last weekend we decided to go to the Khama Rhino Sanctuary for the weekend. I have been there many times since it is in Serowe (where I used to live), but I had never spent the night. A group of 12 went up and we stayed at the wonderful chalets that they have. There was also a great tree for tree climbing (as you can see above ;)

A really pretty ?grasshopper and a Daddy ostrich with babies

We went on a game drive on Saturday afternoon and saw plenty of wildlife. We told our guide that we really wanted to see a black rhino since none of us had ever seen one. In the sanctuary there are 35 white rhinos and only 3 black ones. The black rhinos are also harder to spot as they eat from bushes so stay in the dense parts of the park while the white rhinos are grazers eating grasses in the more open areas. He was on the look-out and managed to find many other things, but no black rhinos.

A lilac breasted roller in flight.
They have the colors of the Botswana flag under their wings, something I never noticed before

We even saw one of the oldest rhinos in the park. Apparently, you can tell by the length and the straightness of their horns - the longer and straighter the horn the older the rhino. Above is a mama and her baby. After 2 hours we returned to our chalets and began to prepare for the brai (South African way of saying barbecue). I wanted to make roasted potatoes, but realized we had forgotten to bring oil. So I headed to the restaurant (a few hundred meters from our chalets) to see if we could borrow some. They were nice enough to let me have a small cup of oil and I started to head back to the brai. As I stepped out of the restaurant I saw a black rhino staring at me! I shouted to the others to bring the cameras and watched as the rhino tapped on the edge of the pool which was covered. He was rescued as a baby, so is more used to humans than the other rhinos in the park and has grown accustomed to drinking from the pool outside the restaurant. One of the park staff members came to remove a section of the pool covering for him and we watched as he stuck his head in the pool and drank.

I offered him some oil as well, but he was not interested ;) After he finished drinking he began to walk towards us so we scattered.

We followed behind him for a bit and at one point he turned around looked at us and then sprayed the area around him to mark his territory. It was quite entertaining.

We returned to our brai and had a great feast which included a nice fire on which to roast s'mores!

Long Time

2011-02-11T16:36:00.000+02:00

Celebrating my birthday with karaoke night and great friends

Has it really been more than 2 months since I have written a blog post? Wow time is flying! At the end of November I went back to the States since my mother was having her foot reconstructed (after 6 weeks on crutches she is now happy to have one foot free of bunions and neuromas), celebrate my birthday, and Thanksgiving. It was great to see family and friends and stock up on some of my favorite supplies (M+Ms, esp the mint ones, peppermint patties and black beans ;)

In Khami Ruins, near Bulawayo, Zimbabwe.

One of the few remaining walls at Khami Ruins. The royal family apparently lived on elevated rock walls on top of the hill (anything they could do to make themselves appear better than the common folk....)

The month of December flew by with a trip to Bulawayo, Zimbabwe over Christmas to see a beautiful national park, rock paintings, and ruins of an ancient civilization (Khami Ruins). I celebrated New Year's Eve weekend in Cape Town which was a lot of fun as it is one of the most beautiful cities ever!

New Year's Eve in Cape Town! (thanks to Alexis for picking out the perfect shirt ;)

I feel like I wrote about these trips since all the pictures are on facebook, but I guess I never did.
I still cannot believe that January is over, it feels like the new year started yesterday.
I have also been doing some work ;) I am still learning a lot from my patients. Here are a few interesting stories.
B.C. is a 17 yr old who is doing really well on his HIV medications. He always has good adherence, his virus is suppressed and he was a seemingly uncomplicated patient. When I saw him at the end of December he said he had no issues, his physical exam was normal and his blood work looked good. We talked about school (he is in Form 5, which is the last year here) and he said it was going okay, but that he wasn't doing as well as he wanted to be doing. He has been getting Bs (which is considered excellent here, esp at our clinic where most patients are getting Ds or Cs). I told him about the tutoring program which we recently started to help kids with their school work since many of them are doing poorly and spend a lot of time at the clinic waiting for the doctors, medications, etc. He was excited and we agreed that he would meet the volunteers coordinating the program that day. As I was printing out his note he said "you know I actually have been feeling kind of empty recently." I turned around. "What has been going on?" It then came out that he has been feeling depressed, has tried to commit suicide (he tried to drown himself in the bath tub) and is having a terrible relationship with his older brother who is his primary caregiver. After several hours of discussion, involving our clinic psychologist, calling his aunt who came in (when I called her at work she dropped everything and came right away - she had sensed something was different, but did not know what to do and he had not told her anything), we worked out a safety plan. He said he was feeling a bit better having told people and both he and his aunt felt that he could be safe at home. He came back the following week and was feeling better having spent the Christmas holidays with his family in the north of Botswana. He is now coming several times a week for tutoring, has brightened-up considerably, and has really formed bonds with the volunteer tutors.

I also got some sad news. B.R. the very sick 10 month old whose house I went to back in Jan (see "Inreach" Jan 29) and who a few months later went missing has died. We tried our best to track down the family last year, getting the local social worker and even the police involved, but we were unsuccessful. This week our in-reach team was finally successful in contacting the mother's boyfriend who told them that the child had died. We do not know what happened and still have not been able to contact the mother (according to her old boyfriend she does not have a cell phone) and get her care. It is incredibly sad to know that B.R. most likely would have been fine had she been able to get her medications. But unfortunately medications only work if you take them and sometimes there is no way to get that to happen.

Other times we are more successful. P.S. is a 6 yr old who was admitted to the wards in January with severe pneumonia and Tuberculosis. At an outside hospital they asked the family for permission to test for HIV and the parents declined. However, since it was medically necessary to know, the hospital sent the test anyway and it came back positive. The child was very sick so she was transferred to Gaborone. When she arrived the team disclosed the positive diagnosis to the parents (it had not been disclosed at the outside hospital) and the parents were quite upset with the fact that the child had been tested despite their objections. The reasoning was explained to them, but they refused to believe the diagnosis and refused to have her retested. The ward team spent a lot of time with the family and the child recovered from her acute illness but they were still unable to convince them of the HIV positive status and need for treatment. So they sent the family to our clinic for further counseling.
The nurse manager and I spent 2 hours trying to explain things to the parents, get them to consent to re-testing (so they could believe the diagnosis) and get them to test themselves. The father (and culturally he spoke for the mother who refused to make any decisions without him) was adamant that no tests be done and wanted to have the opportunity to take the child to a church in South Africa to pray for her. He is a primary school teacher and did have a basic understanding of HIV and said that he did not believe that praying could cure HIV, but he wanted the opportunity to pray for his sick child. After much discussion and talking with the wards team it was agreed that the family would take the child to South Africa for the weekend and then return to the wards to have further discussion. When the family did not return to the clinic as expected the following Monday we called the father who said he was still not ready to have the child tested. However, he eventually did bring the child back to the wards that night. Further discussion reveled that he thought that I (and the rest of the doctors) were on a mission to prove that his child was positive for research purposes (though we had never mentioned research of any kind). So our social worker (whom he had not met and did not associate with the clinic) spent 5 hours with the family trying to come up with a solution. At that time we had gotten the child's CD4 count back and it was 20 (showing that she was incredibly immune suppressed and needed to start treatment ASAP). As this issue was quite urgent, they told the father that they might have to involve the police and what little child protective services there are here if he did not agree that the child needed treatment. At that point the father took the child and the mother and stormed out of the hospital. We were all worried that we had lost them and were planning to contact the police to try to find them. However 24 hours later, the family returned. The father had taken them all to a local testing center and they had all been tested and came back positive. He brought the results to the hospital ward and apologized to the ward team for not believing them. The next day we started the child on medications and the parents will go to have their CD4 count check to see if they need to start as well. It has only been a week, but so far it seems that the family is giving the medications well and we remain hopefully that things will continue to go well.

So things are not always what they seem. Sometimes the "stable" patients are actually the ones who need the most help and the ones who you think will never see the light eventually come around. Of course, there are also the times, as in the case of B.R., when despite all of our best efforts we cannot reach an acceptable arrangement. And I have also re-learned that sometimes patients just need time to come around and feel in control of the situation. And of course gained even more appreciation for the importance of a team approach.

Soweto Marathon

2010-11-15T00:12:00.004+02:00


Botswana group plus Duncan on far left (Baylor PAC doc in Swaziland)					.	Duncan, Bri, Premal, Matt, me, Amit, Gelane, Philip

November 7th was the Soweto Marathon. There was no way I was even thinking about running a marathon, but who would give up the chance to do a 10 km walk through one of the most famous and culturally important neighborhoods in the world?
We drove down to Joburg on Friday after work, arriving later than we had hoped. We were staying at a bed and breakfast in Soweto. Unfortunately there are two streets with the same name in Soweto, only one of the streets housed our B+B the other was in a rather dodgy part of Soweto and was the one the GPS chose to take us to, oops. Luckily the people who owned the bed and breakfast were extremely helpful and sent their son out to meet us and show us the way. Gotta love small family owned operations. The B+B was great. There were only 4 rooms and each had a lot of character

Here we are in front of the B+B

On Saturday we spent the day exploring Soweto. We started with a game of football with some of the children in the neighborhood.

Then we walked down Vilakazi Street (where Nelson Mandela, Desmond Tutu and other famous people lived). We made our way to the Hector Peterson Museum. Hector Peterson was a 13 yr old boy who was killed by police on July 16, 1976 during a youth march protesting the use of Afrikaans as the medium of instruction in South African schools. The museum was a tribute to him and all the others who died in the struggle. It was well done with lots of photos, descriptions of the events, and videos. Amazing to imagine 13 yr olds fighting and dying for a cause when many of today's 13 years can think of nothing but TV and play station.


The fountain outside the museum (no photography allowed inside). The picture is of one of the older youth carrying Hector with his sister walking alongside screaming.

After lunch on Vilakazi Street we headed to the University of Joburg where there was a Barista Competition. Baristas (coffee makers) from all over the city were competing to see who was the best one. I never knew there was so much technique involved. Each barista had to make 4 espressos, 4 cappuccinos and 4 of a speciality drink, which they invented, in 15 mins while judges watched their every move. They were even judged on whether the coffee that was pressed into the machine was completely level...It was kind of crazy but we got to drink some really good cappuccinos (unfortunately the drinks made by the baristas in the actual competition were only for the judges).

We had dinner at Wandie's Place (a famous restaurant in Soweto). Not my favorite food as it was traditional South African buffet, but there was really not much for vegetarians (though the butternut squash was really good ;) Went to bed early since we had to be up at 5 am for the race which started at 6:30 am! The race left from soccer stadium (one of the new stadiums built for the World Cup) and the route was through Soweto which involved some rather large hills! There were over 11,000 people participating (about 5,000 in the marathon and the rest either walking or running the 10 km).

Walking to the start did not count as part of the 10 km ;)


The walk started 10 min after the run so we got to see the winners of the 10 km run coming back. Here they were passing the 8 km mark after only 20 min! And many (as you can see here) were running barefoot!!!

Here we are going up one of the longest hills. It was seriously 1.5 km of straight uphill!

Around the 9 km mark and still going strong!

We finished in 1 hr on 35 min (I know it says 1:45 but the walk started 10 min after the run and the timer was for all of the 10 km ;)

The winner of the marathon finished in 2 hrs and 20 min!!!! He ran 42 KM (26 miles) in 2 hours and 20 min and ran across the finish line like he had just gone for a little jog! He was from Lesotho where there are also a lot of hills!

After the race, in our matching race shirts, trying to capture a jump shot

IN case you want to see more photos here is a slideshow of many more....

New Diagnosis

2010-10-28T21:47:00.000+02:00

Most days in clinic I see patients who are on anti-retroviral medications (ARVs) and are doing excellently. Today for some reason was different. Amidst the routine check-ups and failing teenagers I saw three children who were newly diagnosed. Luckily the number of newly diagnosed children is decreasing all the time in Botswana, so I can often go for a whole week without seeing one. Anyway I thought I would share their stories (I've changed their names).

Mpho is a 12 yr old boy who looked to be about 8. He came to clinic with his older sister. He has been sick on and off for many years now, but never sick enough to get admitted to the hospital. Recently he has had persistent diarrhea (often a sign of HIV infection and something that qualifies him to start on ARVs without even waiting for his CD4 count). His mother has also recently become sick and so his older sisters decided that both he and his mother should be tested. They both tested positive last week. His mother will get started on medications at the local clinic near where they live, but his sister wanted him to be seen at the children's center, so she brought him in. He was quite shy and did not really know why he was there. When I began to tell him about the bad guy in his body that was attacking his soldiers he said he knew that they bad guy was HIV. I asked what he knew about HIV and he said "there is no cure." "That is true, but there are very powerful treatments and with those medications you can live a long and healthy life and be anything you want to be!" He smiled a bit. We sent his baseline blood work, started him on prophylaxis against opportunistic infections, and had long discussion about the importance of adherence and who will help him with his medications. He will return next week to start ARVs.

Nametso is a 7 yr old who came with her mother and her baby sister. She is severely wasted with almost no fat on her body. Her mother is on ARVs already, but for some reason no one ever thought to test Nametso until today. For the last few weeks she has been coughing (occasionally blood tinged), has had fever on and off, and has night sweats (all signs of likely TB infection). Today her mother brought her to be tested and our rapid tests confirmed our suspicions that she is in fact positive. Luckily her baby sister is negative (she was born while the mother was on treatment). Cases like hers really make you realize the importance of asking about all family members and if they know their status. I try always to ask about siblings, parents, etc of the patients I am seeing and we stress the importance of this in the trainings we do, but it it is easy to forget in the course of a busy clinic day. Before we can start her on ARVs, we need to figure out if she has TB. She had signs of pneumonia on examination and I would have liked to get a chest x-ray, but the machine at the hospital has been broken for the last 2 weeks. So I treated her for bacterial pneumonia and arranged for her to get a sputum induction tomorrow (since children are often unable to cough up mucus we have a procedure to help them do that). Unless she gets dramatically better on the standard antibiotics, we will likely empirically start her on TB treatment since it is a hard diagnosis to make in children. And then she too will be started on ARVs.

Then there was Precious. She is 8 months old and was born to an HIV positive mother who actually got the Prevention of Mother to Child Transmission package. However even with the current prevention measures in Botswana, there is still a 4% chance of transmission (<1% in developed countries where women are started on full ARV therapy, given C-sections, and formula feed their babies). She seems to be one of the unlucky 4%. She came today with severe oral thrush. The thrush is so bad that she has not been eating or drinking well and was moderately dehydrated. For the last 4 months she has not gained any weight. She looked severely wasted, dehydrated, and pale (likely also has anemia). One look at her and I knew she had to be admitted. She was tested for HIV back in March (as per the guidelines babies born to HIV positive mothers should be tested around 2 months of age), but the results were never returned. No one told her mother to bring her back for repeat testing (despite the fact that she has not gained weight in 4 months which is often a sign of HIV infection in children) and it wasn't until she got sick that she was brought for repeat testing. With babies we have to do PCR testing which takes at least 2 weeks to get results, but looking at the baby I am pretty sure she will be positive. I walked her over to the pediatric medical ward and discussed the case with the medical officer. He placed an IV, drew blood, and admitted her to begin to rehydrate and stabilize her. We will find out her status for sure in 2 weeks and she will be started on treatment then (assuming it is in fact positive).

Another interesting case of today was Thato. He is 15 and came to clinic with his mother. They were both diagnosed in 2004 and neither has been started on treatment yet. They are both clinically doing well (some patients are able to ward off HIV for a long time before becoming sick). We have been monitoring his CD4 count and it has been steadily dropping over the last year (a sign that he needs to start ARVs soon). However, he and his mother are not ready to start. His mother has found some molasses which is supposed to boost the immune system and they have both started to take that. They are both pretty knowledgeable about HIV and understand that molasses is not a cure for HIV and that the only treatment for HIV is ARVs. His father is actually already on ARVs and doing really well. However, they feel that before starting a life-long therapy all other options should be tried and she wants to see if the molasses will work to boost the immune system and prolong the period of time before which medications have to be started. When I pointed out that the CD4 count was dropping despite the molasses she told me that was because she had not been able to afford the molasses for all of the last year, but that over the last month they were consistently taking it. We agreed to repeat the CD4 in a few weeks and if it is less than 250 (the cutoff in Botswana, though the World Health Organization now recommends 350 and in developed countries it is recommended that patients start way sooner,) he will start ARVs and if it remains high we will continue to wait.

It was a rough day, but luckily they aren't all like this!

KITSO

2010-10-15T23:20:00.000+02:00

Sunset over Serowe. Somehow it is one of the most beautiful places to watch a sunset I have ever experienced

Kitso is the Setswana word for knowledge. So it was chosen as the name for the HIV trainings that occur throughout Botswana. Since 2001 these trainings have taken place around the country to train health care workers about HIV, the adult HIV trainings are conducted by the Botswana/Harvard Partnership and the Pediatric HIV trainings are done by Botswana/Baylor. This past week was my first time as presenter for the Kitso and I got to do it in Serowe (my old stomping grounds). One of the medical officers from Baylor, Margaret, and I traveled to Serowe on Sunday and Monday morning began the week long training. We had 30 participants, one pediatrician from Bangladesh who has been in Botswana for 4 months, 3 medical officers from India, Zambia and Botswana, 2 Nurse prescribers, many nurses, a dietitian, a social worker, and a few pharmacists all of whom work at the main hospital or the surrounding local clinics. Monday and Tuesday were long days of lecturing on everything from epidemiology to diagnosis and treatment. We tried to make it as interactive as possible and after an initial period of shyness the participants began to contribute.

On Wednesday we traveled to the hospital to do the practical portion of the Kitso. We split the group into 5 groups of 6 and they began to interview and examine patients. Margaret and I bounced from room to room helping them along as needed. Many of them were surprised to find 12 year old children who had no idea why they were taking their meds. Prior to attending the kitso they had assumed that parents and caregivers were disclosing the reasoning behind the medications to the children. But what they found confirmed what we had taught them - most caregivers are reluctant to disclose to children and do not know how to do it, leading to children being lied to about the reasons and often getting traumatically disclosed when they are older.

One 5 yr old needed her blood drawn for a lab test and one in the group was qualified to draw blood. So I donned a pair of gloves and got the needed equipment setting out to draw blood as I have done numerous times in the last year (I have actually gotten much better at drawing blood and placing IVs since being here where there is no IV team or phlebotomy team who are comfortable with children as there was in residency). The girl was not happy with me and was sitting on her mother's lap screaming, but I manged to get the blood from a vein in her arm. As I took the needle out with my left hand and held pressure over the site with my right thumb I managed to somehow nick my right thumb with the needle. The needle pierced the glove and there was a little drop of my blood forming under the glove. My first needle stick injury. I immediately expressed as much blood as possible from my thumb and washed my hands, but there is still a slight chance of transmission (0.03% chance of transmission after a needle stick if you do nothing). So I have started on what is called Post Exposure Prophylaxis (PEP) (basically I am taking 3 HIV medications for the next 28 days to prevent transmission.) With 3 drug PEP the risk of transmission after a needle stick is extremely low, so I am not too worried, but I am truly experiencing what it is like to be on ARVs. Luckily I have not really had many side effects (many people experience pretty severe vomiting while on PEP but so far I have had nausea and a weird taste in my mouth but have been able to tolerate the medication overall.) However the medications have to be taken 2 times per day with food and the same time each day. So I will have to wake up early on the weekends, make sure never to miss a dose, eat dinner at around the same time each day, etc...All of the things that my patients have to deal with every day for the rest of their lives. I am lucky that I only have to deal with it for a month, but it is really giving me a taste of what life is like for my patients and an even greater understanding of just how hard it is.

Back at Kitso training, the participants presented the cases of the patients they had seen and we discussed all they had learned. One said, "It was actually a wonderful experience because now I see, wow I really have not been doing this right!" Friday morning we gave them the post test and found that most had learned a lot compared to their pre-test scores. 90% of them scored greater than 80% and all but one passed. I just hope that they will be able to put this knowledge to use, since many do not actually work in the ARV clinics and will not be able to use all that they have learned everyday. But if those not working with it every day, at least learned the diagnostic principles and that every person who presents for any kind of health care in Botswana should be offered an HIV test, I will be happy.

Plenty of reasons to be cheerful, since it is now spring time in Botswana. Everything is in bloom, including this plant, which I planted in Serowe and then transplanted when I moved to Gabs and which continues to thrive!

Mozambique

2010-10-07T22:21:00.001+02:00

Last week was Botswana's Independence day, so we had Thursday and Friday off of work. Bri, Gelane and I decided to take the first three days of the week off as well and take a week long trip to Mozambique. It was an incredible week. We traveled to the Barra Peninsula, which is on the Southeast coast and spent the entire week in a beach house 100 meters from the ocean. The region is known for great scuba diving, so we decided that it would be a great opportunity to learn to scuba dive. In four days we went from not knowing how to put the gear on, to scuba diving 15 meters deep and swimming with sea turtles! It was a crazy experience. The first two times I tried, I freaked out and did exactly what you are not supposed to do - come back up to the surface. But I had a great scuba instructor who held my hand and led me down again. By the third try, I was having fun. It feels really weird to breath through your mouth the entire time and to have this mask in our mouth and on your face that you cannot remove. And the popping of the ears was a constant feeling for the rest of the week.

But eventually we got the hang of it and got to swim with sea turtles, manta rays, fish, etc. Each day we would get up go scuba diving in the morning, have a relaxing late morning, eat lunch and often go diving again in the afternoon. The placed we stayed was fairly isolated and since we did not have a car we spent a lot of time eating and hanging out at the bar next door. We made some friends with German tourists, Welsh tourists, a South African Family and the bartenders, scuba instructors, etc. Most days we had the beach to ourselves which was incredible.

On Saturday morning we went snorkeling with the whale sharks! After a week of scuba diving it was hard to get used to not being able to dive down and we spent a lot of time drinking ocean water! Snorkeling is quite a challenge in an ocean because each time a wave comes you get a ton of salty ocean water in your snorkel. But it was quite cool to swim after giant whale sharks!
All in all, it was a great week and as usually pictures tell the story a lot better so here is a slideshow....

Flying Outreach

2010-09-23T22:42:00.000+02:00

Since Botswana is so spread out and the majority of the country lives on the Eastern border, there are many parts of the country which are extremely rural these areas have few doctors and usually no specialists. So a local NGO has organized charter flights to some of the sites which are the farthest from Gaborone. They fly the plane above which seats 8 (9 if some one sits on top of the area that can act as a toilet in extreme emergencies) plus the 2 pilots. Each Tuesday it flies specialists from Gaborone to a different area of the country (repeating on a monthly basis to cover 4 areas with monthly visits). There is always a Botswana/Baylor Pediatric HIV specialist and a doctor from the Botswana/U. Penn program who can help consult on more difficult medicine patients. Depending on the site there are other specialists from the government hospital as well (including orthopedic surgeons, nutritionists, and even an ultrasound tech who brings a portable ultrasound machine). Last Tuesday, we (A family doctor from Botswana/Upenn, a TB specialist from Botswana/UPenn, a diabetes nurse from the Gaborone govt hospital, and I) went to Ghanzi which is all the way on the Western boarder of Botswana. Since the plane is small, it is more subject to the winds and since they were strong on Tuesday it took us almost 2 hours (rather than 1.5hr) to fly from Gaborone to Ghanzi. The pilots are excellent though, so it was really a smooth flight. We arrived at the Ghanzi "airport" which is really a collection of small trailers and buildings and there was no one in sight.

The Passenger waiting room is never really used, so they have filled it with a small collection of artwork, more like a museum than an airport waiting room and aptly called the "passenger terminal shed."

After about 15 min a van from the hospital came to drive us the 10 mins from the airport to the hospital. The hospital is situated on the outskirts of town (so that they could make it nice and big). Which makes it hard for people from the town to get to it without transport (much like Serowe). However, it does look nice.

There is really nothing right around the hospital just a lot of empty land

We finally arrived at the hospital around 10:30 and I headed to the HIV clinic to begin seeing patients. I worked with a nurse prescriber to see 10 HIV positive children many of whom were either failing treatment or had multiple medical problems. One 17 yr old girl had the worst case of oral warts I have seen. Warts (caused by the virus HPV) are more common in immunocompromised patients, because they are unable to fight the virus and thus it spreads unabated. She had warts covering both her upper and lower lips and her tongue. Unfortunately there are not many treatment options available other that ARVs (antiretrovirals) to boost the immune system and enable it to fight the HPV. However, you can imagine the distress that this would cause a teenager (she has been dealing with it for years) and since it takes a long time to improve, she keeps stopping her ARVs because she feels it is not getting better. I spent a lot of time trying to convince her to stick with the treatment and hopefully she will stick it out this time.

We saw a 1yr 8 mth old baby who was still not walking, not talking and had just started to attempt to crawl (a skill normally obtained around 8 mths of age). And a nine year old who could not hear well, had never really talked, and had never attended school. These children are the hardest, because there are no services available for them out in Ghanzi. There are only a few places in the country where hearing can be tested (critical in both these cases) and they are all 100s of kilometers away. There is only one speech therapist in the country and she is in Gaborone. And the only special education schools that I know of are in the two bigger cities (Gaborone and Francistown). For the baby we were able to refer her to the physical therapist (luckily there is one in Ghanzi) and for both I tried to encourage their mothers to take them to the nearest place where their hearing can be tested. The nurse also informed me that there are some times when the ENT doctors come on the flights and might be able to do hearing testing then, he was going to investigate and then let the mothers know when to come back. But without special education and lots of therapy, and possibly hearing aids, these children will never reach their full potential, and even if they were in Gaborone these would be really hard to come by.

Another complicating factor is that a fair number of the patients in Ghanzi are San (a tribe that lives in the Kalahari desert and many of whom were resettled into towns by the Botswana government when they made the Kalahari protected land, much like what happened to Native Americans in the US). Therefore many do not speak Setswana (much less English), so communication between health care workers and patients is especially difficult. Also they have a lot of traditional medicine practices and it has sometimes been a challenge to get them to take ARVs. Only one of the patients whom we saw on Tuesday was San and her mother spoke very good Setswana and was committed to the treatment, so it was not really an issue this visit.

After seeing all the children in the HIV clinic, I went to the pediatric inpatient wards to see if they had any cases they needed reviewed. The medical officer was not around, but the nurses asked me to see a 3 yr old severely malnourished child who was not walking or talking. There is a strong possibility that the child has HIV and I recommended an HIV test (something that really should be routine on every inpatient admission in this country, but seems to be missed a lot of the time despite our nagging). If the child is positive, ARVs will likely help. Otherwise we will be stuck with many of the same issues faced by the other developmentally delayed children, lack of appropriate special services. It is frustrating to feel unable to provide any real solutions.

We headed back to the Ghanzi airport at 5 pm (eating a lunch of crackers, granola bars, and oranges in the car) for our almost 2 hour flight home, feeling that we had done some education and treatment, but still there was so much left untouched.

Fun Times in Gaborone

2010-09-20T15:46:00.000+02:00

Over the last few weeks we have had many opportunities to have fun in Gabs (as Gaborone is affectionately called). We discovered that karaoke is offered every Thursday night at a local bar. The bar, called The Tavern, has an scandalous reputation late at night and on the weekends, but we have had only the best of times there on Thursday nights singing up a storm of 80s and 90s tunes!

So when we decided to throw a big birthday party for 4 different people's birthdays, we hired the karaoke guys to come to our house. Once they got over their shock that we did not own a TV (they brought their own), they agreed to come for 2 hours of awesome entertainment. Everyone had a great time and then the party turned into a dance party lasting until 3 am.

Shikata, Becca, Jay and Bri (the birthday people) and their cake. They just so happened to sit in the right order too ;)


Group Karaoke, we didn't let the fact that there were only 2 mikes stop us from singing along!

This past Friday, Ringo Madlingozi was in town for a concert at Botswanacraft. He is a big star in South Africa and came to preform in Botswana for the first time. It was a sold out concert (which in Botswana means 1,000 people). It was also the night before Yom Kippur so for me was an interesting substitute for Kol Nidre. The night began with the Botswana Jazz Quintet, which includes our friend Matt Dasco on the sax! After only 2 months here, he was already in the music scene and now, after a year in Bots, he is playing with the top guys!


Matt on the Sax

Then Eugene Jackson (a local Motswana star) and his band played.


Eugene Jackson

Then Ringo and his band took the stage. He sings in Zulu, so I had no idea what he was saying but it didn't matter. The crowd was so into it, singing every word, and it just felt so great to be there listening to his beautiful voice.

It felt like a very personal concert, because there are no assigned seats and the venue is very small by US standards. So we stood and dance right in front of the stage all night.

Gelane, Premal, me, Bri and Parth during the break between artists

The rest of the weekend was spent fasting, relaxing, reading, swimming, and watching Gizmo climb trees.

For those who don't know, Gelane and her cat Gizmo, (a cat who she rescued when he was a tiny baby kitten starving in front of our clinic and because he is all black he is considered bad luck here so no one wanted him), moved in to my house in the end of June. And though I have never been a cat person, I have grown fond of Gizmo (when he is not trying to attack my foot - for some reason he has a foot fetish). He is a crazy cat, climbing trees and up on the roof, trying to attack cats who are bigger than him and stalking all sorts of things (though luckily, so far, he has only managed to capture bugs). Despite his craziness, he is very cute and can often be found curled up in my lap (as he is right now) trying to redeem himself for all the times he has tried to attack our feet or jumped up on the kitchen counter during the day.
Happy Jewish New Year to all those who celebrate it, and may this year bring joy and redemption to us all!

Camp Hope 2010

2010-08-30T23:38:00.000+02:00

He was led in by his aunt on Sunday morning with tears pouring down his face. It looked like he was being sent to a horrible place and yet O.T. was coming to Camp Hope. At 10 years old, he had never spent a night away from his aunt and now was going to be away for 4 nights in a row. Not knowing what to expect he was sad and scared, asking to be taken home. One of our Setswana speaking doctors and a social work student spent over an hour walking around with him until he warmed up. After a few hours he was marching with the orange group singing the team cheer. By the end of camp he was asking if he could come back next year!

Camp Hope is a camp that is hosted every year (for the past 6 years) for children who attend our clinic. I wrote about it last year as well (see Aug'09), but this year I knew the children a lot better after taking care of them in clinic for the last year and I was able to spend more time at the camp. Once again I was reminded of the extreme burden that HIV places on these children's lives. Most of the children are at least single orphans (having lost one parent) and many are double orphans (having lost both). Our clinic has over 2,000 children and we can only take 50 children at camp each year. So we restrict it to children ages 10-12 years and try to invite those who have more complex issues (poor adherence to medications, lack of social support, psychological problems, etc). It is always hard to choose who should be able to go because really they should all get the chance.

We try to make camp completely about having fun. The children are all given their medications twice (or in some cases more often) a day. They all get to see that everyone at the camp is taking medications and they are not alone, but otherwise we don't mention HIV. There were different activities each day arts and crafts (they each made hope dolls, decorated and dressed in style as above and below), dance, exploring feeling and emotions, sports, cooking and nutrition, and character development and each of the 6 color teams rotated through the activities getting a chance to try each one out.

We took a trip to Mokolodi, the game reserve and educational center, which is only 20 mins from the city and yet the vast majority of the children have never been there to see some of the animals that bring tourists flocking to their country each year.

We also had Camp Hope Olympics which involved everything from sack races to trying to eat donuts tied to stings with your hands tied behind your backs.

I played the role of camp doctor, face painter (see some of my handy work below - and yes the face painting was all done by camper request, not sure why she wanted a giant US flag on her face, but ask and you shall receive when at camp), human jungle gym, arts and crafts helper, and I dispensed plenty of hugs! It was a great week and a chance for everyone to just have fun and be a kid.

At the end of camp on Thursday morning the caregivers were all invited for a slide show of photos from the week and the children performed the song and accompanying dance that had been our theme song for the week. R Kelly's "I'm the greatest." Watching 50 HIV positive children dance and sing "I made it, I'm the world's greatest" brought tears to my eyes. (If you don't know the song you can find it on youtube: http://www.youtube.com/watch?v=LyaNlZaVOpc, I can't post the video of the kids dancing because not all of them have photo consent, but take my word for it when I tell you it was incredibly moving) At the end of the presentation, a caregiver of one of the 11 yr old boys came up to me and thanked me for inviting T.S. (her nephew) to camp. She said "when I dropped him off on Sunday he was really shy and now I see that he has made friends and he is up there dancing, it is so amazing."

Each camper received a certificate of participation or graduation depending on their age and if they will be eligible to come back to camp next year. They were all so thrilled.

We would really like to offer camp twice a year (April and August - to coincide with the local school vacations). But we have to raise the money to be able to do that, so if you are reading this and you (or anyone else you know) wants to donate please click on the button on the sidebar "donate now" and mark your donation for Camp Hope or contact me ;)

Nigeria

2010-08-17T21:29:00.001+02:00

The first week of August Gelane, Andres (2 other PAC doctors) and I went to Nigeria with Hospitals for Humanity (a US based NGO which conducts medical missions in Nigeria and Haiti). It was an eye opening experience. Nigeria is the largest country in Africa with over 150 million people, quite a contrast to Botswana with only 1.8 million. We were in Lagos and working primarily with the community of Makoko (a water based community where people live in the water in raised "houses." We stayed in a hotel and security was very tight.

Security at the hotel was a bit different than what we are used to back home in Bots (our security guard in Botswana carries a cattle prod). Armed guards came with us each morning in our van, though I think a lot of that was to make us feel better since we did not witness any altercations of any kind.

Each morning our van was escorted by the traffic cops (Lastma) this was mostly to help us get through the unbelievable stand-still traffic. These guys were pros, riding motorcycles while looking backwards and weaving in and out of traffic to clear the way for us.

We were working with the local state government which organizes medical missions throughout Lagos. So we got the chance to work with several Nigerian doctors (mostly those who had recently finished medical school and hadn't yet done a residency). But they were very good at their jobs. Our "clinic" for the week was the local primary school. We had no place for labs or other tests, only our clinical judgments were used! Each day the patients waited under tents until their number was called. Over the course of the week we saw around 10,000 patients (between the eye screen, mobile dental truck, and medical doctors)!

Wonder what the school looked like before the renovation, scary thought.

One day the door to our classroom was locked and no one could find the key so one of the workers removed a pane of class and helped one of the children who was waiting to be seen climb through and come around to open the door

Gelane was a local TV celebrity as she was interviewed by the local news crews who came to report on the medical mission being carried out

Gelane and an adorable baby!

The best slogan ever! It was on all their porta-potties and their truck which carted them around the city.

Learning the Nigerian dance steps at the BBQ following the week long mission. My teacher (one of the local doctors) then asked me to teach her the traditional American dance, but I was not really sure what that was. I explained that we don't really have one, do we?

Five children sharing the one drink which was left over after the BBQ. No complaining or pushing occurred they all just shared it and were so happy to have it.

The whole Hospitals for Humanity group, mostly from the US, but there was a Nigerian doctor and nurse from the Northern part of the country where missions have been conducted before.

After the mission with the Lagos State Department of Health was over, we went to the water community where most of the people we had worked with during the week came from. There were heavy rains that day (the only day it really rained was of course the one we were planning to spend on the water, despite the weather people saying >80% chance of rain for every day of the week!) The roads around the dock area were flooded. Most people just drove right on through it, though it did cause problems for at least one car we witnessed.
The water community was like nothing I have ever seen. Here is a video (I hope) of the trip back from the "school" where we saw patients. I put school in quotes because it was a sorry excuse for a school, everything was broken, it was incredibly dark and every time people walked on the second floor dust flew on those of us seeing patients on the first floor, not a good place to learn...

There are so many more photos so here is the slideshow of the best 240 of them, including a few more videos ;)

A busy Saturday

2010-08-14T13:29:00.001+02:00

On July 31st our Teen Club covered grief and bereavement for the younger teens. We had 80 teens split into 10 groups. After asking them to act out a few feelings as a pictionary type game we moved on to the main activity. Drawing picture boards of the saddest thing that had happened to them. We began by drawing the time when they were last happy before and after the event. Then the worst part of the event and then they filled in the boxes in the middle to tell the rest of the story. More than half of them drew stories of a parent, aunt, or someone close to them who had died. One girl drew about her brother committing suicide which had happened only a few weeks before. She became very emotional, luckily we had counselors on hand and we were able to refer her to the psychologist to be seen the following Monday. Many drew about car accidents or other accidents. It was a very intense activity. I think for many it was one of the few opportunities they have to be open and honest about their feelings as Botswana culture is very private when it comes to emotions. Children are encouraged to keep quiet and not really encouraged to share how they are feeling. In the end a teen leader summarized the activity by saying "we all have challenges and each one makes us stronger."

That afternoon, I went to my first Botswana wedding (one of the nurses at our clinic married his finance who has just returned from getting her MBA in the UK). At Botswana weddings, the entire village is invited, as well as family and friends who live elsewhere. Botswana weddings last all day and people come and go throughout the event. The actual marriage often takes place earlier in the day with just the couple and the family, so everyone else only comes for the party.
For the first few hours people ate and talked, we missed a lot of that thanks to teen club. Then the couple and bridal party began to dance for everyone. They had choreographed dances and all the guests stood around and watched.

The couple changed outfits at least 4 times. From the white dress to the suit to a traditional blue outfit and finally Indian style saris. Apparently all couples change clothes, but the number and type of outfits are dependent on the couple's preferences.

There was also a hired group of traditional dancers

And of course there was plenty of shake shake (the traditional sorghum and maize beer brewed locally).

Plenty of cute children were present

One YEAR!

2010-07-28T22:00:00.000+02:00

Today marks my one year anniversary of arriving in Botswana! I cannot believe that a year has passed. In many ways I feel that I have lived in Botswana for a long time; and in other ways I feel that it was only yesterday that I walked the halls of St. Christopher's Hospital for Children complaining about difficulties with booking an MRI (if only I had known what it would be like here....) So I decided in honor of my year anniversary I would attempt a Top Ten List. (There is no way that I can compare to my Uncle Mark's legendary Top Ten lists, esp without the drum rolls, but here goes...)

Top Ten Surprises About Botswana

Number Ten:

You can drink the tap water straight from the tap and it tastes great

Number Nine:

I live in a nicer house than almost anywhere else I have lived, complete with a swimming pool, microwave, wireless internet, and monkeys instead of raccoons!

Number Eight:

Driving on the left side of the road is not that bad after awhile.

Though learning stick, left handed in the bush is not so easy

Number Seven:

It gets really cold here in the winter, especially when you don't have central heating!

And man are the summers hot!

Number Six:

All produce comes from South Africa, almost nothing is grown here except cattle (which I hear are really good, though being vegetarian I have not had the pleasure of tasting the grass fed beef).

Number Five:

Above mentioned cattle (as well as donkeys and goats) are everywhere (in the city, on the highway, in the middle of the road)! There are more cattle than people here and the cattle are not afraid to cross the road (or stand in it) at any time of day or night, despite the fact that cars are coming at them at 120kms/hr

Number Four:

It is possible to get very close to some really dangerous animals and live to tell about it.

Number Three:

The hospital wards are never "full" (there is always room for mattresses on the floors) and the mothers are expected to act as housekeeper, laundress, cook, nurse, and monitoring system.

Number Two:

The fact that the hospital can run out of Normal Saline, Iron tablets, and Bactrim (all basic medications) but have Vancomycin and Cefotaxime (more expensive antibiotics) in stock.

Number One:

The unbelievable resilience of children and the incredible size that a smile can grow to when a child is presented with a sticker and a complement on a job well done!

My first year in Botswana has been filled with many great surprises, numerous trials and tribulations, and more learning opportunities and adventures than I can count. There are many, many more than ten, but I thought the above list was a good start. I feel so lucky to have been able to have this experience and am looking forward to all of the surprises that year number two will bring.

Adventures in the Kalahari

2010-07-25T20:00:00.000+02:00

July is the month for Botswana Holidays. July 19th and 20 were two days off to celebrate President's day. So for me and 7 friends it meant a good chance to explore the Central Kalahari Game Reserve. We drove to the Northern section of the park which took us around 10 hours! Which meant plenty of time for me to work on a new scarf pattern ;) (Argosy from Knitty for those who care ;)

After arriving at the park the first order of business was to collect firewood.

We then drove through the reserve for 2 hours to our campsite. Arriving in the dark we managed to set up camp and cook a nice dinner of steak, veggie burgers, corn, and veggies over the fire. It was delicious.

Our camp site the first night

The next morning, we woke up early to go to the nearby watering hole and see if any animals were around. We did not see any animals, but I learned to drive stick shift! Driving stick in the bush was quite an experience.

Learning to drive stick.

As you can see it is pretty cold in the desert.

There is a drastic temperature difference between the heat of the day around 22C and the nights which were around 4C!)

In many ways a good place to learn as really no one else on the road but stopping for animal sightings meant stalling quite a few times :)

After breakfast and some relaxing at the campsite, we made our way to the next campsite. On the way we saw bat eared foxes (above), many antelope, and some birds.

Riding on the roof provide an excellent scouting position!

We did not make it the entire 120 kms to the campsite that we had reserved so we decided to set up camp at an empty campsite which we had passed. We cooked a nice dinner of pasta and veggies and were sitting around the fire eating s'mores, when we heard hyenas calling. A few of us went to investigate to see if we could see the hyenas. Shining the spotlight in the direction they had been calling we saw a pair of eyes staring back at us around 20 ft from the camp, but could not make out the body. We decided to pack up all the food and put it in the cars to keep it safe for the night. While packing the food someone noticed that what we thought was a hyena was in fact a leopard! Upon saying this everyone made a bee line for the car. Five of us climbed into one car with 3 on the roof, shining the spotlight in the leopards direction. We watched as the leopard stalked occasionally looking at us, but moving parallel to us and then suddenly there were two leopards (probably a mother and adolescent child because they were around the same size and leopards are usually solitary animals). Leopards are also usually very shy around humans, but these two did not seem to be. As we watched they walked around our campsite and seemed to be stalking something other than us.

After it was clear that they had left we resumed packing up the food figuring that animals do occasionally walk through a campsite (this was after all the bush and their home much more than ours). But then suddenly we spotted them again from the other side of the campsite. They had in fact circled the site moving silently around us. Now this was weird, as apparently leopards are not interested in humans as prey. So we decided that it would be best to move campsites. However, we did not feel it was safe to take down the one tent that we had set up (it was a 6 person backpacking tent and 2 people had been planning to sleep on the roof of the car - now no longer a good idea since leopards sleep in trees and are good at pouncing). Luckily we still had a 4 person canvas tent in the car. After quickly going into the tent for some sleeping bags and to make sure all the food was gone, we piled into the cars and drove off in search of a another site. At this point it was 10 pm and pitch black. As we drove we arrived on the leopards stalking a bat eared fox. We watched them for 10 mins and decided that they were far enough from our campsite that it would probably be okay to go back to there. We made our way back and set up the canvas tent in between the two cars (to provide extra protection). One person remained on the roof with the spotlight scanning the area. Just as the tent had been erected she spotted a leopard again! However, at this point if we had moved campsites we would have had to go without tents, so we decided to stay put. Two people slept in each car and four people slept in the canvas tent (I was one of the people in the cars)! We propped all of the camping chairs against the tent in case the leopard came back it would make noise knocking down the chairs, since they are silent when they stalk. As far as we know the leopards did not come any closer that night, in the morning we found their footprints all around the camp but none came closer to the tent than about 15 feet. (close enough for me though).

Unfortunately we did not get any photos of the leopards since it was pitch black they would not have come out, plus we were a bit too scared to think about photos. We did get photos of the footprints though. These are crossing our tires tracks, so were definitely made after our final trip back to the campsite.

It was probably one of the scariest nights of my life but now that we are all safe it does make a good story as it is pretty incredible to be so close to a leopard let alone two!

The whole gang after surviving the night!

The next morning we searched all the trees before making breakfast, but did not see any leopards sleeping or otherwise. After packing up camp we headed out and back towards Gaborone, driving out of the desert we saw a black mamba (one of the largest and most dangerous snakes) slithering along, away from our direction (thank goodness!). After another long drive back we arrived safely in Gabs, happy to have lived to tell the tale.

Salt Pans

2010-07-12T22:51:00.000+02:00

July 1st was Sir Seretse Khama day, a day to celebrate the first president of Botswana and a day off work. So it meant a long weekend and a chance to explore more of Botswana. We traveled about 600 km to the northern central part of the country to see the salt pans. Makgadikgadi Pan comprises several smaller salt pans and is one of the largest salt flats in the world (6,200 square miles). Millions of years ago the Makgadikgadi lake was there but as it dried up it left behind a salty desert.

After a drive to edge of the pans, we took quad bikes through the pans. It was amazing to look around and see nothing but open salt pan for miles! Our guide led us to a "campsite" where they built a fire and cooked a delicious dinner. After some guitar playing by Matt, singing, dancing, and s'mores around the campfire, we tucked ourselves into bed rolls (mattress with tons of blankets all in a canvas zipping bag to fend of the cold desert night) for the night. No tents just an unobstructed view of the sky! It was cloudy so though we did not see any stars, we did wake up to a gorgeous sunrise in the morning

The desert is home to the Meerkats (only found in the Kalahari desert)

So the next morning we quad biked back to the safari vehicle and went to visit meerkats. These adorable animals live in family groups. At least one always acts as the "sentry" (like the one above) keeping look out for predators while the others look for food. They eat mostly insects and other small animals, but they also seemed to take time out from searching to play fight.

There is a guide who spends his days following around this family of meerkats, so that they will not be too scared of humans. So when sitting still in the middle of them they will sometimes use you as a large rock from which to get a better view, or simply crawl over your foot.

We then ventured to the largest baobab tree in the region. Chapman's Baobab. It was used by explorers hundreds of years ago as a landmark and "post office" (apparently they left letters for each other in it's holes) on the Cape Town to Cairo route. Baobab trees are amazing, they store water in their swollen trunk (up to 120,000 litres (32,000 gallons)) in order to survive the desert dry seasons. This one is supposedly thousands of years old.

The fruit of the baobab is interesting. The outside is a hard shell covered in a soft stringy material. As I am always game to try new things (right, Dad?) I decided to crack it open and see what was inside. I found seeds covered in a white substance and stingy fibers. I asked one of the staff at the lodge and was told that you eat the white substance that surrounds the seeds. I cannot say it was my favorite thing, in fact it tasted like a sour sawdust, but apparently it is really rich in vitamin C and calcium....
After a night at the lodge, watching some incredible though sad world cup games (the Ghana loss). We began to make our way back to Gaborone. On the way we stopped at the Nata Bird Sanctuary. We were shocked to find a lake with pelicans and flamingos. If you squint you can see the pink flamingos in the middle of this bunch (they were really far away).

Since Botswana is a landlocked country this is the closet we can come to a "beach." We had a nice stroll along the muddy beach and spotted a heron, a few little brown jobies (sorry, mom can't name them all ;), and a scorpion.

Mt Kilimanjaro!

2010-06-24T22:41:00.002+02:00

The roof of Africa!

On Saturday June 12, as the rest of Southern Africa was glued to their TV screens to watch the World Cup, I set off the climb the highest mountain in Africa. I went with a team from Maasai Moja (a wonderful company, whom I would recommend highly), Ayesha (a fellow PAC doctor who has been in Tanzania this past year), and Cabrini and Mike (2 Peace Corps volunteers who just finished their two years in rural Botswana). We set off on Saturday for a 7 day adventure. For 6.5 days we climbed up, (though sometimes down as well so that we could properly acclimatize by "climbing high and sleeping low") finally reaching the summit at 6:45 am on June 17th. I got mild altitude sickness on the last day (headache and some dizziness) as well as wicked blisters, but it was all worth the feeling of exhilaration you get from standing on top of the highest point in Africa.
I think a slide show with captions is the best way to tell the story, so here you go (it ends with a video - you have to click on the video to be able to watch it)....

And now it is back to World Cup fever, which has totally sucked me in (hard not to be into it when the festivities are happening in your neighboring country!)

Traditional Medicine

2010-06-21T00:03:00.001+02:00

After a brief trip back to the US to see my brother graduate from law school and my cousin get married, (both wonderful events), I returned to Botswana to start my last week on the inpatient wards (June 6-10)!

(Just to back up for a minute for those who don't know. I have moved back to Gaborone, the capital, permanently. Our program is being downsized to begin the transition to more local control. We started the year with 9 PAC (Pediatric AIDS Corps) doctors and 3 are leaving us. So it was decided that there could no longer be 2 people in Serowe all the time. Also we had already accomplished much of the basic training and now need to focus on teaching local providers to manage challenging patients (or those who are not doing well on standard therapy). So we have started "challenge clinics" and will be traveling to the area twice a month to see patients who are failing. We are also going to be pulling out of the inpatient wards as there is now a pediatric residency program and several new pediatricians who are going to cover our team. Hence I have completed my last week on the wards. From now on I will be working in our clinic, doing outreach, trainings, etc)

So the week began with being on call on Sunday (June 6) when I met Thabang a 3 month old male who was previously healthy, but had developed vomiting and diarrhea 3 days prior to admission - he was admitted on Friday. His paternal grandmother took him to a traditional medicine doctor who gave him several teaspoons of a liquid that was greenish in color. About three hours later he began to breath very very fast and was very tired so his mother brought him to the hospital. He was found to have severe metabolic acidosis, renal failure, liver dysfunction, and was very sick. As part of the work-up a lumbar puncture was done on Friday night as he had a fever and was very ill appearing and the doctors needed to rule out meningitis. He was given a lot of fluids, antibiotics, oxygen. etc. When I arrived on Sunday he was still the sickest patient in the wards. I did a lot of counseling of the mother to explain that he had a very poor prognosis. All of the doctors involved in his care over the weekend felt that the most likely cause of his condition was the traditional medicine ingestion. The traditional medicines have multiple different herbs and other medicines mixed together and most of the traditional medicine doctors are used to treating adults. We have seen numerous cases of children who have developed renal failure following traditional medicine ingestion. Unfortunately there is no way to be exactly sure as we do not have any way of testing for them in the blood. We also do not have dialysis which could potentially clear the toxins from the system. So the only treatment we can offer is supportive care and fluids to reverse the dehydration and metabolic acidosis. Thabang's mother seemed to understand the severity of the situation and also to understand what had caused it. The baby was still breathing very fast in an effort to get rid of the carbon dioxide (CO2) in his body, but I was worried that he would get tired.

On Monday morning he was in fact getting tired. He was now breathing very shallowly and his blood gases showed that he was not blowing off CO2 as well as he had been before. He needed to be intubated to have any chance of living through the day. We had another family meeting this time with the mother and the paternal grandmother. The paternal grandmother was furious. She was convinced that the lumbar puncture that had been done on Friday night was the cause of his illness. She said that she had a family member who had died after a lumbar puncture. For over one hour I tried to explain the risks of lumbar puncture (which absolutely can not cause renal failure or liver dysfunction) and why we had done the lumbar puncture. She spent most of the time yelling at us in Setswana which was translated to me. Eventually I could see that we would get no where and told her that I understood how she felt about the lumbar puncture and I was sorry that she felt she had not been consulted (after all the mother is the one who has the right to give consent) but that I could reassure her that it had not contributed to his decline and that what we needed to do now was focus on Thabang and trying to make him better. She eventually agreed to disagree. I then spent 6 hours trying to get a doctor from the ICU to come and evaluate Thabang and see if he they might be able to take him in the ICU. Eventually they agreed, though so much time had passed that we almost lost him in the transport. He was admitted to the ICU on Monday night and intubated, but despite our best efforts he passed away late Tuesday night.

On Wednesday morning I arrived to find Thabang's mother and both of his grandmothers waiting for me. They wanted to discuss what had happened. I sat down with them again and explained what I knew with the help of a nurse who translated whatever was not understood. But both grandmothers remained focused on the lumbar puncture. Now they were most concerned with the fact that the intern on call had obtained consent from the mother without involving either of them. The mother is 22, very smart, and has full legal right to consent for her baby, but the grandmothers felt that they should have been consulted. Unfortunately there is no formal consent process here for things like lumbar punctures, everything is verbal. After over 2 hours of discussion, I think the grandmothers still believe that the lumbar puncture is in some way responsible for the baby's death. I assured them that we will work on better ways to document consent, but unfortunately it is not really practical to convene a full family meeting every time any sort of procedure needs to be done. I felt very frustrated. After working so hard to do everything possible for the baby, the family believed that we were the ones who had caused the death. It is one of the many examples of the challenges of combining western medicine with traditional beliefs and stressed to me again the importance of good communication (and documentation of that discussion) from the very beginning.

On a happy note, Chuma (the 9mth old I wrote about in the last post) was started on antiretrovirals (I paid for the first month's supply) and finally began to improve. He was discharged from the hospital after a month stay and will be getting medicines from a non-citizen clinic and from Zimbabwe (when he is able to return).

Citizen?

2010-05-13T18:05:00.000+02:00

Chuma is a nine month old male. His mother brought him to the hospital because he was having trouble breathing and a fever. When he arrived he was extremely sick with hypoxia (low oxygen levels), severe respiratory distress, malnutrition and lethargy. His mother did not receive prenatal care and is HIV positive so his chances of getting HIV are around 50% (since he was also breastfeed, babies who are not breastfed have around a 25% chance of getting HIV from pregnancy and delivery without intervention). We started him on intravenous antibiotics, oxygen, IV fluids, and steroids, treating him for both PCP pneumonia (a type of pneumonia that occurs only in patient's who are immunocompromised) and for bacterial pneumonia. We also began a work-up for TB, HIV and started treating his malnutrition. But his biggest problem is that he is not a citizen of Botswana. He was born here, but his parents are from Zimbabwe and because of that he may not survive.

As I have mentioned before, the Botswana government provides free health care (including antiretrovirals to treat HIV) to all citizens. However, non citizens are not given the same treatment. They can be seen in local clinics and hospitals, but they have to pay for each service. For example, if I want an x-ray for a citizen all I have to do is fill out the paper, of course the machine has to be working and the paper has to make it to the x-ray department, etc so sometimes it takes a whole day, but eventually they will get an x-ray. If a non-citizen needs an x-ray they have to collect the funds, (around $15 which sounds cheap, but when you make $200/month if you are extremely lucky to have a "well paying job" (many people are unemployed or working "piece" jobs so are not making money when their children are in the hospital) it gets expensive quickly), take the money to medical records, get a receipt and then take the receipt and the form to the x-ray department.

The biggest problem arises when the patient is HIV positive. Prevention of Mother to Child Transmission (PMTCT) is fairly effective in Botswana. If mothers follow the complete protocol (complete with free formula from the government) there is only around a 4% chance that the baby will end up infected. This is, of course, still higher than the risk in the US which is less than 1% chance of transmission for a mother who follows the full protocol. Non-citizens are not provided with PMTCT or formula so their risk of transmission is much higher. Once the baby is born they need to be tested for HIV with a HIV pcr test around 6 weeks of age (cost $22) and if it is positive they can be started on treatment right away (the sooner you start treatment for a baby the better the outcomes in the long term). Treatment has gotten a lot cheaper over the years with the advent of generic drugs but the cheapest treatment for babies is around $35 a month (since the liquid suspensions are more expensive then pills).

It seems like it would be easy for well meaning doctors and nurses to foot some of this bill, but it is dangerous to start treatment without knowing if the patient will be able to continue because stopping the medications will breed resistance. It is heartbreaking to watch these children go without treatment, and often die, just because their parents are from a different country. Of course, I can also somewhat understand where the government is coming from because they are struggling to provide care for all of their citizens as it is, but nevertheless humans are humans no matter which country they come from. There are a few doctors who have started a fund to support non-citizen HIV treatment, but with the economy as it is, the fund has dwindled to almost nothing. If anyone reading this would like to contribute to this fund, please let me know and I will give you the details. For now I hope that Chuma can make it through his acute illness, so that we can try to help his parents afford the testing and drugs that he, most likely, desperately needs.

Nambia

2010-04-29T19:36:00.000+02:00

A typical street in Swakopmund which the guide book says is a town more German than Germany
(having never been to Germany I will have to take their word for it, for now).

Easter weekend in Botswana meant a four day weekend (no work Good Friday or Easter Monday)! With four free days you just have to take a trip somewhere, right? Gelane and I decided that we had never seen Namibia and since it borders Botswana it is possible to drive there, thereby requiring very little planning. The only problem with going to Namibia is that all the fun things to do are on the coast which is 1,500 km from Gaborone! No problem we had 4 days to make the round-trip ;) We set off on Thursday evening after I finished with the inpatient wards and began to drive west. Of course it was raining which that makes people here forget how to drive, (it would be really scary to see them in snow), and everyone was trying to leave the city, so it took us forever to get out of the city limits. Nevertheless we made it to the small town of Kanye the first night and stayed at the Kanye Ultra-Stop (gas station, store, restaurant, lodge, camping site all in one) getting the last available room. The next day we set out early and began the 12 hour drive the rest of the way. About 4 hours later we crossed the border which was rather complicated on the Namibia side because it involved buying a road permit for the car (luckily we had thought to bring South African Rand which are accepted in Namibia, as of course they only take cash and there was no ATM). Driving through Namibia felt much the same as driving through Bostwana, desert with small green shrubs, but there were at least mountains in the distance (which we don't get to see much). The capital of Windhoek apparently has some interesting museums and theater but of course everything was closed on Good Friday. Finally we reached the Namib Desert and the landscape changed to beautiful sand dunes.

There were even signs to remind you that there was sand, (um duh we see it)

We arrived at Swakopmund after dark on Friday night and had luckily called ahead to book a room in one of the few hotels that had space. Exhausted and hungry we set out to find food, but were disappointed that many of the restaurants were closed. Nevertheless we finally found a really good fish restaurant with an upstairs section playing live music. It was a nice dinner, but we could not help being surprised at the lack of nightlife and street life in a tourist town where every hotel was booked. I still don't know where everyone was.
The next morning, after a German style breakfast buffet (more kinds of meat then I have ever seen and a look of shock on the owner's face when we said we did not want bacon with the eggs), we set off for quad biking and sand boarding (the big attractions in the town).

Gelane showing her quad bike who is boss!

After a quick lesson on how to work the bike we set off into the dunes with 4 other women and our guide. Driving the bike was pretty easy once we got the hang of it. I felt a bit like a dare devil traveling over uncharted territory (though we were following our guides tracks to minimize the environmental impact and avoid the sudden drop offs). All the while taking in the gorgeous scenery...

This was the largest drop off that we rode down in our bikes. It was pretty scary at the top as it was a straight drop and it seemed the bike might topple over. Here the guide is trying to talk one of the girls (from Germany) into going down it, he was unsuccessful and ended up bringing her down on the back of his bike during which she screamed in his ear the entire time! After bungee jumping it was really a piece of cake ;)

Then we stopped the bikes for an hour of sand boarding. Basically you are given a sheet of compressed cardboard which they have rubbed down with some kind of lubricant and then you lie on the board pull up the edge and lift up your feet, get a little push and go flying down the sand dune. It is great fun though you do get covered in sand by the end and then you have to walk back up the sand dune. We decided that we could have done it all day if only there was a chair lift or other means of getting back to the top.....

We then got back on the bikes and made it to where the ocean meets the dunes which was a wonderful sight.

After a trip back to the hotel for a much needed shower, we spent the afternoon in Walvis Bay a town about 30 km from Swakopmund. It has an interesting history in that it was part of South Africa (as it was a valuable port city and they did not want to give it back) up until 1994 when they finally gave it over to Namibia. It used to be that when you wanted to visit the town you actually had to cross a border even though everything for hundreds of KMs was Namibia. It also provides 90% of South Africa's salt which is collected from the Salt pans (below). For some reason flamingos really like the salt pans so there are tons of them there.

After some shopping Sunday morning we began the long trek back to Botswana. We spent the night in a small town 100 km from the Botswana border in a very cute bed and breakfast and then Monday made our way back to Gaborone. All in all a lot of driving, but worth it for the amazing time we had on Saturday. Plus the drive was quite enjoyable as we listened to podcasts from NPR, chatted, sang along to music and I got a ton of knitting done (when I wasn't driving, of course). Stay tuned for pictures of the finished projects, they just need to be blocked....

Passover

2010-04-17T23:27:00.000+02:00

So this was Passover in Botswana (yes I know it was three weeks ago, sorry I'm a bit behind on the blogging...) Given that there is really no Jewish community in Botswana, (no synagogues, no chabads, very few Jews), I was not really expecting to get a chance to celebrate the holiday. Luckily Matt had other plans. He managed to find a Haggadah online (again what did we do before internet?), printed many copies, and invited all of our friends to his and Premal's house for a seder. There were 20 people at the seder, only 4 were Jewish, and most everyone else was at their first seder. To our surprise, there was even matzah in the local supermarket and the visiting cardiologist's wife made matzah ball soup (after a trip to South Africa to get the matzah ball mix). We had a proper seder with everyone taking turns reading from the Haggadah and much discussion relating history with the present. We even had two children to find the Afikoman at the end!

It was a wonderful way to celebrate the holiday, and though I missed being with my family, I was thrilled to have so many people to share Passover with.

I know the last few blogs have been all about fun trips and celebrations, but don't worry, I have also been working ;) The last week of March and first week of April, (in addition to being Passover), were two more weeks on the inpatient wards. I find the inpatient wards to be the most challenging part of the job here. I have always been a person more aligned with outpatient medicine and the children on the wards here are often extremely sick (the opposite of outpatients). I often find myself managing children who belong in an ICU and often the outcome is not good.

In two weeks there were three deaths on our team, all children less than one year old who came in severely ill. One had been given traditional medicine and had gone into renal failure and had severe respiratory distress by the time he came to the hospital. One had severe meningitis, and the other had severe respiratory distress and a VSD (hole in her heart). All three would probably have benefited from an ICU, where they could have been intubated, given ventilator support, dialysis, etc. However, that is not really available here, as we only have an adult ICU and they rarely accept pediatric patients. So we did our best for them on the wards, but unfortunately it was not enough. It never gets easier to tell a parent there is nothing more you can do for their child (nor should it ever get easier). Doctors are supposed to be able to make things better and it is hard not to feel defeated when you can't.

However, for each of the defeats there were a lot more battles which we won. During those two weeks there were also a number of children with gastroenteritis and bronchiolitis, (both things that I had a lot of experience managing back in the states), who just needed some supportive therapy (IV hydration, oxygen, etc) and TLC and managed to be discharged in a day or two. Watching the dehydrated and lethargic children become animated and playful and the child with croup who finally improves with nebulized adrenalin and steroids; makes it possible to continue the fight.

As we say on Passover: "Next year may we all be free." To me this is not just free from slavery, but free from persecution, poverty, unnecessary deaths, war, inadequate health care, etc. A lofty goal for a year, but I hope with each passing year we will be one step closer!

Safari!!!!

2010-04-11T15:05:00.000+02:00

Here we are with our favorite guide, Marks, after a walking safari

At the end of March, My parents and brother came to visit! I met them in Maun (in Northern Botswana) and we flew in a six seater (including the pilot) to several camps in the Okavango Delta. It was hardly camping as the "tents" were complete with beds and bathrooms and more luxurious than many hotels I have stayed in! We saw 160 species of birds (my mother was in heaven and kept track of all of them), elephants, giraffes, cheetahs, lions and their cubs, buffalo (and lions stalking them), warthogs, zebras, hippos, a hyena, rhino and more! We had an amazing time and have thousands of pictures. I have spent many hours trying to sort through the pictures and pick out the best ones so here is a slide show I have created with some of the highlights (since each picture is worth a thousand words, I'll let them tell the story with a few captions ;)

Cape Town!

2010-03-07T12:02:00.000+02:00

The last weekend in February I went to Cape Town! We took Thursday and Friday off from work and made a long weekend out of it. Cape Town is hands down one of the most beautiful places I have ever been! We rented an apartment in Campus Bay (a area of the city which is right on the water).

The view from the living room!

The apartment overlooked the beach and even have a roof top deck with a jacuzzi! (Unfortunately the winds on the roof were unbelievably strong and the water in the jacuzzi never got hot, but we did not let that stop us!).

We began our weekend with a trip to Robben Island (where Nelson Mandela was imprisoned for 18 of his 27 years). We took a 45 min ferry ride out to the island (it is only 12 km away but the boat was slow) on one of the boats that use to take prisoners to the island. We were given a tour of the prison by an ex political prisoner who was there from 1980 to 1991. The prison is very bleak and the way they treated the prisoners horrendous. Below is a picture of Nelson Mandela's cell, barely enough room to move around and he was kept in it almost 23 hrs a day for much of his time there.

The next day we took a drive down the coast to Cape Point. The views were unbelievably beautiful.

Then we went to Simon's Beach to see the penguins. So funny to see penguins not on ice! These are African Penguins, but I guess they still like freezing cold water because the water was insanely cold! This one is braying (the mating call which really sounds like a donkey - it is for this reason that they are called "jackass penguins").

The next day we took the cable car up to the top of Table Mountain and enjoyed walking around the top where we got to see views of the whole city and the ocean including an aerial view of Robben Island.

We finished off a great weekend with a wine tasting at Delaire Estate. Unfortunately it is harvesting season so they do not allow wine tours but we still got to taste several of their wines and enjoy more gorgeous views!

I spent last week in Serowe and I am about to leave for another week there. Next Saturday my parents and brother arrive for safari! Will be sure to post some pictures upon our return!
I'm experimenting with the slideshow feature so I have tried to create one of the trip to Cape Town below (not sure how to make it only show some of the photos so be sure to skip around as there are 374! sorry ;) Not sure if it will work but here goes:

SOS Children's Village

2010-02-21T22:14:00.000+02:00

I realized that I had never written about my trip to SOS Children's Village almost a month ago when I was in Serowe, so here it is! SOS Children's Village is a sort of foster home/orphanage. They have a really unique set up with individual houses so the children can feel part of a family. In Serowe (there are 2 other villages in Bostwana, but all three have waiting lists as there are many children in need) there are 9 separate houses each with 10-14 children and 2 "house mothers." The "house mothers" have their own families, but they live at SOS most of the time, returning to their own families 3 days every two weeks. The children in the houses range in age from babies to 18 year olds and boys and girls are mixed so that the children have "siblings." Most of the children are orphans, though some are placed at SOS after being abused or neglected, and many have HIV. Most have connections with their biological families (grandparents, aunts, uncles, etc) but for whatever reason their families cannot take care of them. However, many go back to their biological families for school holidays. I went to visit to check up on a patient who we had referred there and found her and her "siblings" to be thriving.

This is the front of her house. The children and house mothers can decide on what type of gardening and landscaping to do in front of the house and many had vegetable plots.

It only took a few minutes for the children to warm up to us. We brought along some stickers which, as you can see, were a big hit. Trying on our sunglasses also provided much entertainment. But they got the greatest joy by being picked up, swung around, carried, hugged, etc. It wasn't long before I was a human jungle gym. I certainly felt sore the next day, but it was well worth all the smiles and laughter ;)

I returned the next week to play chess with some of the older children (though they promptly beat me, since I am very out of practice!)

I will surely be a frequent visitor when I return to Serowe in March!

Teen Club

2010-02-07T22:48:00.000+02:00

The first Teen Club event of the new year was the last Saturday in January. A record number of teens turned out, 137! As usual we split them into two groups (13-15 and 16-19). The older group did a lesson on communication. For the younger group it was Sports Day! Several adult volunteers and I, took about 80 13-15 year-olds to a nearby field. We started off with a huge game of Red Rover, Red Rover (above). And then they broke into groups based on which sports they wanted to play. There was net ball (kinda like basket ball), tennis, volleyball, football (soccer) and even hula hooping and jump rope. I played football and was really no match for most of the kids. Luckily the weather cooperated. After days of torrential downpours alternating with oppressive sun, we managed to have our sports day on an overcast day with no rain. As a result it was only about 85/90 degrees with a nice breeze! The kids all had fun. The best part about days like that is no one would know that any of these children have a chronic disease and they just get to have a great time!

On a random note, I thought you all might appreciate some pictures of the neighborhood equivalent to raccoons. Yes they are monkeys! The spend their days eating the garbage, swinging from the telephone lines, and chasing each other across the roof. Every once in awhile I will hear what sounds like thunder and is actually monkeys running across the roof. One of the other doctors left her door open for 15 mins to get some fresh in the house and the next thing she knew 5 monkeys were in her house eating her bread and peeing all over her kitchen! They had climbed through the bugler bars and were having a grand old time! Not so fun to clean up, but at the same time hard to get mad when they are so darn cute! They remind me of the children's book "Caps for Sale".

Inreach

2010-01-29T22:26:00.000+02:00

On Monday I saw B.R. she is now 10 months old and weighs 3.7 kg (the weight of a very large newborn and well well below what a 10 month old should weigh). She had disappeared from the clinic for the last 2 months and had run out of her medication for the last 6 weeks (very dangerous when you are dealing with HIV which can easily develop resistance). Her mother only came to clinic after one of the nurses had noted that she hadn't been around in awhile and called the mother begging her to come. She said that she had lost the baby's outpatient records (each patient here is responsible for caring around their medical records in a stack of tattered papers) so she thought she would not be seen. We assured her that we would always see the baby no matter what. I wanted to admit the baby to the hospital for stabilization of her nutrition status, but her mother was worried about what would happen to the 6 other children at home. See here little children must be accompanied by a caregiver in the hospital. The nurses are not responsible for feeding, changing diapers, etc. I understood her point and given that they baby was not in significant distress (as this has been going on for months) I agreed to extremely close follow-up. I involved the clinic social worker, dietitian and several of the nurses. After 1.5 hours we had a plan and B.R.'s mother was in agreement that she would return to the clinic 2 days later so that we could assess the baby again and review the results of blood we took on Monday.

On Wednesday they did not show up. I had a long discussion with the nurse in charge of the clinic about where to go from here. We agreed that we would go to the patient's house on Thursday and see what the issues were. (At the clinic there is an "inreach" team that goes out to visit the homes of patients with complex social issues). We talked about the possibility of placing the child in foster care, as clearly the mother was having significant issues caring for her, but that is really hard to do in Botswana. The places that take care of neglected and abused children are full and have waiting lists. There is one emergency option that cares for babies for 3 months but it is really a last resort and when the child has a mother the mother must be taken to court and charged before the child is accepted. Admitting the child was another option, but she had been admitted for the same issues in October (though that time she was sicker) and nothing had changed about the home situation so the baby was back where she had started. We called the phone numbers she had given us but they did not work. Luckily we had the address though very confusing because there are no street names in addresses here, just an area of the city, a plot number, and "near the Total gas station," not easy to find.

On Thursday afternoon we rounded up a team. A driver from the clinic who knew the area where the patient lived well, one of the nurses and me. B.R. lives pretty close to the clinic. Once off the tarred road we traveled around several dirt roads looking at the house numbers until we finally found the one we were looking for. You really have to know where you are going as there did not seem to be much of a system to me. Our timing turned out to be excellent as B.R.'s mother was just returning home. I took some very discrete pictures of the neighborhood.

From the front the house did not look too bad. But as we followed B.R.'s mother I realized that she did not live there. Rather behind the house were two other structures running parallel to each other, divided by a small alley. There were several doors and the one she opened revealed a very small room. In the room was a 3/4 size bed, a small bureau, and in the corner was the cooking area. With 4 people in the room it was very crowded. There was one window, no fans, and it was 100 degrees! B.R. lives there with her mother and sometimes the mother's boyfriend. Her siblings stay there on occasion as well, but they are often in a village outside the city with their aunt. B.R. was on the bed with a family friend. She actually looked better than she had on Monday. Her mother showed us all of the medications which looked as though they had been taken. We reviewed how to give the medications and mix the special formula the dietitian had given her. She explained that she had not come to the clinic because she had to see the local social worker to arrange for the food basket (Botswana government's version of food stamps).One of the ARV medications was missing, when I asked her where it was she told me that it was in her landlord's refrigerator because it needed to be cold (seeing as she does not have electricity or running water that would have been impossible in her room). She told us that her cell phone had fallen in water and no longer worked (that explained why we had been unable to reach her). We talked for about 20 mins, I examined the baby, and we made a plan to see her in clinic.

Visiting B.R's house made me begin to realize just how many obstacles she is up against. I am still not sure if her mother will be able to care for her, but now I have a better understanding of why. I hope that she will make it back to clinic next week and maybe she will even have gained some weight!

Moremi Gorge

2010-01-22T17:56:00.000+02:00

Waterfalls in Botswana? In a country of sandy, dry, flat land the prospect of seeing a waterfall and mountains was very enticing. I had heard of a place called Moremi Gorge near Palapye, of course it was not on any maps or road signs, so I made a trip to the Botswana Tourisim office in Palapye. They gave me directions typical of those I have received since arriving in Bostwana: “Go down this highway here (pointing), turn right at the billboard with all the villages on it, drive down that road for awhile past the first sign to Moremi. Turn right at the brown sign for Moremi village, take that road until it ends at the Kgotla [village civil court] and then someone there will help you.” Okay seemed easy enough.

We (Gelane, Dany, and I) set out on a hot Saturday morning (temp according to the car’s outside thermometer was 38C or 100 F at 10:30 am and promised to climb higher. After a relatively uneventful drive during which we passed very few other cars or people, but many cows and donkeys, we arrived at the village. There were plenty of houses (mostly traditional huts), many cows, and 2 boys sitting in the shade sharing an MP3 player. The road we were traveling on ended at a building, which the boys informed us was in fact the kgotla. But no one was there. We asked the boys which way to the gorge, but they had no idea and said they did not speak English (though they did know enough English to ask us for money). So we parked the car and set off to find some people. After many false starts and many people who did not know what we were talking about, we finally found a man who knew. He went off to find the manager of the kgotla. She opened the building had us register, (the last visitors were a week before – no wonder they don’t staff the building 24/7), charged us an entrance fee (30 pula ($4.50) each and 30 pula for the car) and asked if we wanted a guide (another 30 pula). Given the fact that when she pointed out the “road” to the gorge we questioned what had led her to call the grass with the faintest of tire tracks a road, we thought a guide would be a good idea. She went off to find one and 15 min later brought back “Charles.” Charles was a cheery guy with a nice smell of alcohol on his breath and very minimal ability to speak English, but we were not exactly in a position to be picky. 1.5 hours after arriving in the village we were on our way.

"The road"

Charles pointed us toward the hills and, with me driving my trusty CRV, we set off for adventure. After about 2 mins. we got to a dry riverbed with a relatively steep hill, I was skeptical but one Charles just kept saying “go” so I went. The drive was a good test of the car’s four-wheel drive capabilities and it did amazingly well through the sand, rocks, brambles and amongst the cows. 30 min later we reached a point where we could go no further. Thank god for Charles because there was not a single sign other than one saying “please don’t litter” randomly placed among the trees. Parking the car among the trees we got out and began to hike, again with no trail or signs we were very lucky to have Charles.

The landscape was like nothing else I have seen in Botswana. We were among mountains with lots of lush trees. We reached the first of the waterfalls without difficulty, though we were dripping with sweat the second we stepped out of the car and wishing that we had brought more than 3 (½ liter) water bottles.

“The waterfall” was probably one of the smallest I have seen and yet it was incredible given the landscape in the rest of the country. A small pool had formed beneath it and throwing cool water on our faces proved to be very refreshing. We sat happily for a few mins dunking our feet in the water, walking along the edge of the pool, and enjoying the cool breeze. Then Charles informed us that this was only the first of the waterfalls we could visit. He began to scale the rock face on one side of the pool and crawl along the edge of the rock. We were very skeptical, there was not much to hold on to and falling meant landing on pointy rocks many feet below but we had come for adventure so we crawled after him.

Crawling along the cliff was not as bad as we had thought looking up at it and we reached the second waterfall without much problem. We then climbed higher into the mountains scaling rocks and oftentimes having to swing our legs up one at a time to reach the next level, luckily we are all pretty tall and taller than our 57 yr old guide, so if he could do it….

The view was amazing some of the prettiest mountains I have ever seen. I even discovered Botswana’s equivalent to poison ivy. One tiny brush with the leaves of this plant and you get a burning sensation unlike any I’ve ever experienced. A min later there is a swelling (as if you have been bitten by a mosquito) with some surrounding redness. But luckily, unlike poison ivy, the effect only lasts a few hours and there is no subsequent itching. Of course after I screamed upon touching the plant Charles said “no touch that one.” Oops.

Don't touch this one...

After the third waterfall we were beyond thirsty and Charles assured us that we could drink from the waterfall (after all it is a spring). I was very skeptical, but it was nice and cool and the few sips I had did not cause any problems (and after a few days I can say this with confidence ;) Ironically the only markers we found on the trail were at the top of the mountain – orange arrows pointing one direction or another with no discernable path to follow.

After the third waterfall the path was completely covered and Charles decided that it was not a good idea to continue. We were more than satisfied with all we had seen and anything he called dangerous was certainly not worth trying since what we had already done was “Go same” (Setswana for ok) and I thought it was questionable at points. We made our way down carefully and all reached the car in one piece. All in all, we had an amazing day and were wonderfully surprised to find such a beautiful oasis in the desert.

Disclosure revisited

2010-01-09T18:10:00.000+02:00

This has been a hard week on the wards. But there have been many rewarding moments as well.

On Friday, I was able to discharge T.M. from the hospital after his month long stay to treat cryptococcal meningitis!!!! We bought him a small puzzle and a card that was signed by all the PAC doctors (as we have all taken care of him over the last 3 months since he was diagnosed). He was very happy to leave and excited (though a bit nervous) to start school on Tuesday.

On Wednesday, the clinic was packed and the wards were not too busy; so I went over to help out in the clinic for several hours. One of the patients I saw was an adorable 6 year old boy and we had one of the best clinic visits ever....
I asked him "why do you take your medications"
"To keep my body STRONG!"
"Has anyone ever told you about the masole (soldiers)?"
"No"
"Well then I think Gloria (the nurse) has a good story for you."
"Story, yeah story. Tell me the story"
So Gloria tells him the story of the soldiers that are being attacked by the bad guy. He listens very carefully and answers all the questions right.
"My soldiers have big muscles" he says, flexing his biceps.
Then just as we were wrapping up. He suddenly says "AIDS, Aquired Immunodeficiency Syndrome!" We were all very surprised, where had he learned that? I asked him what it meant. He said "AIDS kills." We talked about how that is not the case if you take your medications. And then he broke into song, which I cannot do full justice to in written form, but just picture a six year old singing this to a catchy tune.

"My name Lerato (none of these are his real name, he made them up) I am a solider. AIDS you CANNOT touch me. I will kill you. (Setswana word that means) "to the ground".
My name is Thabo, I am a doctor, AIDS you CANNOT hurt me, I will inject you, "to the ground."
My name is Nametso, I am a lawyer, AIDS you CANNOT kill me, I will rule you "to the ground"

Gloria, the visiting resident, his mother, and I all cheered him on and he marched out of the room singing and flexing his biceps. Luckily the song was over by the time he reached the line for the pharmacy, where it may have caused a bit of a stir if the other children had begun to ask their mothers what AIDS was. I guess there are some children who are just ready to be fully disclosed to at an earlier age than we might think they are.

Since this blog has no pictures; here are some pictures of our adventurous new year's weekend in Rustenberg, South Africa. We went Zip Lining in the Magaliesberg Mountains.

The longest of the cables, where you could not even see the other end!

Having fun on the trampoline at the hotel the zip lining was based out of.

I am heading to Serowe for the next two weeks for more outreach and mentoring, so it may be awhile before my next post. Hope everyone is having a good start to 2010!

The Wards

2010-01-05T21:43:00.000+02:00

Where do I even start? I guess to warn you that this entry is not for those who are hoping to brighten their day and to apologize for all the medical words (I will try to explain as much as possible)....

See last blog for a partial description of the hospital. I forgot to mention that it is unbearably hot most days on the wards (of course there is no air conditioning or even fans and it has been around 35-40 Celsius (95-104 F) these days). As a result, all the windows are open and so there are always tons of flies, it's a losing battle to try to swat at them...) Here are some stories about a few of the patients I've tried to take care of over the last week and 2 days.

O.N was a 5 yr old diagnosed with osteosarcoma (bone cancer) in July and started on chemotherapy for 2 doses. Then he never came back for chemo as scheduled. He finally returned the day after Christmas with a now humongous arm (the cancer is in his left humerus) and respiratory distress. A chest x-ray showed that his entire left lung was full of fluid, most likely from the cancer spreading. The only pediatric oncologist in the country is a fellow PAC doctor and he was back in the States for the holidays. So our team was covering all the oncology patients. We tried to find a surgeon who would help us to place a chest tube to drain the fluid, but the one pediatric surgeon was not returning our calls and we could not find any other surgeons. So Gelane and I decided to do a thoracentesis (procedure where you drain fluid from around the lung with a needle). I did one thoracentesis in medical school, but it has been awhile. So we read up on the procedure. Then I acted as anesthesiologist (we actually had ketamine and versed!) and Gelane as surgeon. We were able to drain a little bit of the fluid, but not enough to provide the symptomatic relief we had hoped. O.N. tolerated the procedure well, sleeping through the whole thing. He managed to do okay on oxygen for the next 30 hrs until the pediatric oncologist returned. Upon looking at the chest x-ray (CXR), the oncologist was sure that it was a spread of his malignancy and that the reason we were unable to drain more fluid was because what we were seeing on the CXR was spreading tumor. After explaining all of this to the family, he worked out a palliative care plan for the patient. Two days later, just 2 days before the new year, O.N. passed.

T.M. is a 12 yr old with the greatest smile I have ever seen! He was diagnosed with HIV 2 months ago when he was first admitted to the hospital for bad headaches and severe malnutrition (he now weighs what an average 8 year old would weigh). It was discovered that he had crytptococcal meningitis (an AIDS defining illness in that it is pretty much never seen in patients with normal immune function). At the time he was started on treatment for the meningitis and for HIV, he improved and was sent home on a prolonged treatment course. He returned in early December and was discovered to still have residual crytptococcus surrounding his brain. He was begun on an extended course of Amphotericin B (which we are lucky enough to have in Botswana) and after two weeks we did a repeat lumbar puncture. Seven days later it is still not growing crytptococcus, but is not considered to be truly negative until day 10. He, his incredibly devoted parents, and I are all keeping our fingers and toes crossed that it will stay negative and we will have finally rid his body of crypto. He will still need to take medications for cypto for a long time, but at least he will be able to leave the hospital and do what he so desperately wants: to start the new school year on time on January 11! Every day I give him several stickers and his huge smile in response, despite everything he has been through, makes my day.

My first ever call, before tonight, was on New Year's eve. I was in the middle of skyping with my family when the pager went off. When I called back, the voice on the other end said "we need you in the NNU (neonatal unit) there is a baby that won't stop bleeding." In 10 mins I was at the hospital walking as fast as I could from one end to the other (of course the NNU is on the opposite end from the parking lot and in a country where land was not at a premium, the hospital is flat and the distances far.) The bleeding had stopped but the baby had lost a lot of blood. The blood bank was having trouble finding blood that the baby did not react to, but at last they managed. The medical officer (MO) and I talked about the plan and I was getting ready to go home when the pediatric ward called to say that a child in severe respiratory distress had just been admitted. Leaving the MO to finish with the baby, I went over to investigate.

The admission was a 9 mth old baby. His mother had tested HIV negative during her pregnancy, but had not been tested since until 2 weeks prior when the patient had been admitted for failure to thrive. On that admission it was noted that the baby who had initially been normal weight for age, was dropping percentiles at each check. As part of the work up they had retested the mother and found her to be positive. This meant that the baby was at high risk of being infected with HIV, as the mother had gotten it late in her pregnancy and the baby had not gotten any prophylaxis. The test for the baby (a PCR) takes 4-6 weeks and was still pending, so we were unsure whether the baby actually had HIV - however given all the signs I am 99% sure he did. The baby had been discharged and was doing well at home until the 29th when he got a high fever. The mother brought the baby to the local clinic 4 times in 2 days and each time the baby was sent home with Tylenol and some antibiotics. Finally the mother had enough and brought him to the hospital, but by then it was too late. When I saw the baby he was working very hard to breathe, had signs of meningitis and was very tired. We did some blood tests and a lumbar puncture, started antibiotics and oxygen, but it was not enough. It would have been nice to be able to intubate him, but there is no pediatric ICU here and the adult ICU does not take children very often. The baby died 1 hr before the new year. I can not even begin to imagine what it must be like for that mother and I have thought about her a lot over the last week.

There are many more patient stories....There is the 3 month old with a heart murmur and beginnings of heart failure who will have to wait at least 2 weeks for an ECHO since the one person who does them is not available until then. The 6 mth old with focal seizures who cannot get an EEG because the one person who will do them is at the private hospital and the government has not paid him for the patients he has seen for the last year, so he is not seeing any more public patients for the time being. The 2 month old who had not gained weight since birth because there are 11 children at home and no one working, so there is not money to buy food. The numerous children with measles (a disease I had never seen before coming here) as the country is in the midst of a measles outbreak. And the list goes on and on. There are more deaths than I have ever witnessed on a pediatric unit in the States. And yet many patients do get better. I am trying my best to channel T.M.'s happiness. If he can do it, I can too!

Holiday Spirit

2010-01-03T22:39:00.002+02:00

A few weeks ago when I was in Mahalapye the chief medical officer told me about a 14 year old girl who had come in with dysfunctional uterine bleeding, (in this case a very prolonged menstrual period causing her extensive blood loss). Her hemoglobin was 3! Dangerously low and she need a blood transfusion. However, there is a nationwide blood shortage and the hospital was out of blood. He called the two bigger referral hospitals and they said they also were out of blood. I said "well I can donate blood right now." In the States I try to donate every 2 months, but I had not donated since I had been here. It turns out, I even had the same blood type as the patient. However Mahalapye does not have a blood donation system. They have no way to collect, test, or separate blood. The blood donation process can only be done in the two referral hospitals, so that was not an option. Miraculously, after threatening to refer the patient to the nearest of the two referral hospitals, some blood was found and they were sending it by car which was going to take about 4 hours, but luckily the patient was stable.
So last week when I saw the signs for blood donation at the Princess Marina Hospital in Gaborone, I went to donate. Of course, I showed up at the end of work (4:30 pm) and they were just packing up. However they told me I could go to donate the next day at the national blood donation center about 5 mins from the main hospital. The next day was a slow day on the wards (more about that soon), so I went to donate. It was basically the same procedure as blood donation in the States, but with less nit picking. They do have a questionnaire about your habits, through after hearing that I had donated numerous times in the States, my "counselor" marked "no" for all the questions. They check your hemoglobin and your weight, and then voila they are sticking a 16 gauge needle in your arm while you hold the blood bag in your lap.

A similar sticker sheet full of millions of bar codes gets put on your bag. At the end they take two test tubes of blood, as they do screen the blood for all the things we test blood for in the States. Then you get the choice of fanta, coke, or sprite and you proceed to the couch where you find....

An entire package of biscuits and the largest Sprite I have ever seen. I thought the touch of the sliver platter was quite funny. Here women can only donate every four months (as opposed to men who can donate every 2 months, in the states everyone is eligible every 2 months). The difference is that they are worried that women will be more prone to anemia because of menstruation; more of a worry here given the poor diet of many people here.

Last week also marked my first week as attending on the inpatient wards. I have been consulting at various local hospitals when I was based in Serowe, but now that I am spending more time in Gaborone I also will be spending some time in Princess Marina Hospital (PMH). PMH is one of two referral hospitals in the country, and one of the few places where pediatricians staff the inpatient unit. However, we do not have many pediatric sub-specialists, so us general pediatricians end up managing a lot of things specialists would manage in the States. In addition to lack of specialists, we also don't have many of the things one would find in a children's hospital in the States. We don't have child life specialists (people who help children deal with their feelings about illness and fears about procedures), there are no private rooms (the patients are in beds lining either side of several 3 sided rooms), there is no place for parents to sleep (and yet almost every single patient has a parent with them 24/7; they sleep in chairs or on the floor next to the child, or in bed with the smaller children.) Parents provide a lot of the care in the hospital from feeding and cleaning their children, to reminding the nurse when the child's IV fluids have run out, to acting as monitors when the child is really in distress. It can be a really dismal place. But last week I noticed that someone had gotten the children to make wishes for the holiday.

This Christmas tree was up on the wards with each little ornament reflecting the wish of one child. Some were pretty unique.....

Sorry for the poor quality photo, but it says "I wish my brothers liked (or he/she may have meant tickled since the first letter looks like a t) me every second"

While others seemed liked things kids in the States would write. "I want to be a pop star," " I want an X Box 360," or the one above "I wish I had a TV in my room." Unfortunately I don't think that Santa brought these children exactly what they wished for, but at least a local radio station did visit the hospital with some gifts around Christmas.

More stories about the wards in upcoming blogs, but I wanted to share one final photo.

He is one of the children I met in Serowe. He did not want to be put down so he sat on my lap as I wrote notes and finally fell asleep in my arms as I read through one of the other patient's charts. He was so excited to see his picture on the camera, that he could not wait for the photo to actually be taken!

Happy 2010 everyone! I hope this year brings some health, happiness, hope, peace, equality, and the ability to experience small joys through the eyes of a child to all corners of the world!

Christmas in Durban

2009-12-30T12:51:00.002+02:00

So happy to see water and the beach.

I spent Christmas weekend at the beach in Durban, South Africa. We drove to Joburg and then flew the 1 hr from Joburg to Durban. Flying outside the United States is so much less painful! You can bring liquids, leave your shoes on, they deboard the planes through the front and the back doors, etc! Our first day in Durban was cloudy and misty so we toured the city. Being that it was Christmas, none of the museums were open. But we did manage to find a statue of Ghandi.....

Then it was off to the beach. There were several people who had created amazing sand sculptures. They said on average they spend 6 hours or more making the sculptures. They leave them over night but they are often distroyed by the next day and need to be recreated. Interesting way to make a living.

We got really into the jump shots....

After several hours of exploring we were ready to head back to our hotel in a suburb of Durban. We took two adventurous combi rides. Combis are the public transportation system here; they are minivans that travel around the city on specified routes. The first one was in a supped up combi complete with even a TV blaring a cartoon. The second was not as nice and quite cramped but got us where we needed to go.

The second combi ride was more cramped than the first...

The following day was gorgeous, a perfect beach day. We went to the beach in Umhlanga, the suburb where we were staying. It was a totally different beach experience from the beach in Durban. The after effects of apartheid are still very present. On the beach in Durban there were very few white people, no umbrellas to rent, less shops, more garbage and no pretty pier. Umhlanga was the opposite. It was a stark reminder that only 19 years is not enough time to overcome years of oppression.

Gelane and me on the pier on the beach at Umlhanga

Right on the edge

The next day we made our way back to Joburg. Since we arrived in the morning we figured we would make a trip to the Apartheid Museum.

It is an incredibly well done museum that should be part of everyone's visit to South Africa! No pictures are allowed to be taken inside, so you will just have to take my word for it. The museum starts with each person being handed a ticket that says either "White" or "Non-White" and then you have to enter through the entrance that corresponds to what is written on your card. As you make your way through the entrance you see replicas of the passcards which everyone was forced to carry. While both whites and blacks were supposed to carry the cards, only blacks were ever sent to jail for not carrying them (even if they were only going to the corner store for a minute). The museum led me through a history of South Africa, then the creation and abolition of apartheid. There was also a special exhibit on Nelson Mandela. So much to read and see that I spent almost 4 hours in the museum and easily could have spent more. It made me appreciate just how far South Africa has come in the 19 years since the end of apartheid, even though there is still a LONG way to go.

"To be free is not merely to cast of one's chains,

but to live in a way that respects and enhances the freedom of others" - Nelson Mandela

This quote is on the entry wall of the museum. A statement that was truly exemplified by Nelson Mandela who easily could have tried to retaliate against those who had imprisoned him for much of his life; but instead he worked towards creating a country where everyone was equal.
It gives us all something to strive for as we approach the new year...

UNFAIR

2009-12-20T16:22:00.001+02:00

Earlier this week I was asked to consult on a patient on the pediatric inpatient ward in Serowe. I was told that the patient was a 14 year old with heart failure. As I walked to the ward with my fellow PAC doctor (Steph) we wondered allowed what we would be able to offer the patient given our limited experience managing heart failure (after all it is not a common problem in children and not one that general pediatricians routinely manage.) When I started looking through the chart I began to think that the story sounded all too familiar. The patient (we'll call him Tefo) had just been diagnosed with HIV at the late age of 14, he was an orphan, and had just been started on antiretrovirals (ARVs) despite a high CD4 count. Steph wondered why he had been started on treatment. (In Botswana, when a patient has a CD4 count >250 there has to be another reason for starting ARVs - like an opportunistic infection or failure to grow, etc.) And then all of the pieces fell together, Tefo was the same child I had seen just 2 months earlier with his aunt in one of the local clinics (see last blog about disclosure). I had started him on ARVs because at 14 he was the height and weight of an eight year old. As soon as I saw him I knew it was him. He had been admitted to the hospital for chest pains and shortness of breath about 1 week earlier and it was discovered that he had an aortic aneurysm and severe aortic regurgitation. By the time we saw him he was stable and was actually walking around the ward. However, his heart sounded nothing like it had just 2 mths earlier, which means that his heart problems were acute. It is possible that the aneurysm has been there for some time, but has suddenly grown larger causing him to be symptomatic. We are still unsure what caused an aneurysm in the first place, could it be congenital? Could he have Marfan's syndrome? What would Marfan's Syndrome look like in a child who is so stunted (given that people with Marfan's are usually very tall)? We don't have genetic testing available here and the bottom line is that he needs to go to South Africa for heart surgery, since we don't do heart surgery here either. The adult cardiologist who visits Serowe a few times a month, and had been the one to perform the echo and diagnosis the aneurysm, is working on getting an MRI to better visualize the aneurysm and transfer him to South Africa. There was really nothing more that we could suggest, but I was just struck by the unbelievable unfairness of it all. It is not enough that Tefo is an orphan (though he has a loving aunt, she also has her own children), he also had to be diagnosed with HIV, and then he has to have heart surgery as well. And yet there he was smiling at us as we asked him to do all sorts of crazy things in our quest to see if he might meet clinical criteria for Marfan's. His strength gave me hope that he will make it through all of these challenges despite the hand that he was dealt in life.

There have been changes in the grants that we have gotten and in the requests for our time from the Ministry of Health; so I will now be spending about half of my time in Gabarone and half or so in Serowe. It will be a good chance for us to see how much the medical officers we have mentored have learned and it will be an opportunity for me to become involved with some other projects which will be interesting. It also means more consistent access to internet so I will try to update the blog more often ;)

I have had some time to knit recently and since this blog has no pictures, here are two of my recently completed baby sweaters (since many people I know are having babies and they are fun and cute to knit). Thanks Mom for blocking and sewing the buttons on the first one ;) They are both the same pattern (the sideways sock yarn baby sweater), which is my new favorite baby sweater pattern (for now). It is excellent because there are really no seams so when you are done you are done! This is great since my least favorite part of knitting is sewing it together at the end.

Disclosure

2009-12-01T15:26:00.000+02:00

It's World AIDS DAY! That fact did not mean that today was different here than any other day; since it is something that we deal with everyday. But it is good that people elsewhere are maybe acknowledging the problem today. There have definitely been many changes for the better in regards to HIV and AIDS in the last 10 years, but we still have a long way to go. And we have challenges today that we could not really imagine having 10 years ago. One of the major challenges is the teenagers and young adults. Ten years ago children who were born with HIV in Africa did not make it to their teenage years. Today, with the increased availability of anti-retrovirals, their numbers are raising steadily (as I have mentioned before). This is a wonderful thing - all these children who would not have lived are surviving and thriving. However, as if being a teenager was not hard enough, they find out that they have a lifelong illness that requires lifelong daily medication! How they discover this information is critical to how they will be able to process what they hear and can have an impact on the success of their treatment. Many of these children have been taking medications their entire lives, but in most cases no one has given them any reason to take the medication other than "because I told you to" or "you are sick" (which if they are taking the medications properly they often feel perfectly healthy). Many begin to question why they should take medications when in fact they feel healthy.

Baylor has developed a stepwise process of disclosure so that the children are not lied to and the process is begun at a very early age. It comes with a flipchart of pictures and uses the analogy of soldiers and bad guy to explain what HIV is. The name HIV is not used until children are ready which can be anywhere from 9-14 or so, depending on their development. It only takes a few mins to explain this analogy to children and then the idea is refreshed at each visit and new concepts are added on. However it does typically require someone who speaks Setswana and does take an extra 3 or so mins. In many of the busy local clinics patients are seen by doctors who do not speak Setswana, there are no designated translators, and often patients spend a total of 5 mins with the doctor. All of these are huge barriers to disclosure and many of the medical officers feel that it is the caregiver's job to tell the children anyway. The caregivers often have no idea how to go about telling children and many have a lot of guilt over giving their children HIV. As a result, most of the children at these clinics have no idea why they take the medications or will say "because I am sick." I spend a fair amount of my time trying to explain what is really going on in a way that they can understand (that is after I have tracked down a translator!)

Here are two recent examples.

I was waiting at one of the local clinics for transportation to a clinic 60 kms from Serowe, when one the nurses approached me and asked if a patient (who had been referred from another clinic where they do not dispense ARVs) was eligible for ARVs. The patient was a 14 yr old boy who was living with his aunt. He had been sick a few times during his life and recently had had chronic diarrhea. His mother had died when he was young (his aunt assumed from AIDS, though the mother had never been diagnosed). The aunt had brought him to the local clinic for an HIV test when the diarrhea did not resolve after a few weeks. I went to see the child and his aunt. He looked about 8 years old, he was severely stunted and underweight (a common problem in children with untreated HIV). He was very quiet. We talked for awhile about his history; I examined him, and ordered the lab tests we would need before starting medications. It is quite rare for children to live 14 years with HIV without being very ill. But it is possible that he had acquired it slightly later in life through breastfeeding (as those were the days before formula was available to mothers who were HIV positive). We talked to him about whether he had ever had sex (which he denied) and whether anyone had ever made him do anything he did not want to do – to attempt to ensure that he had not gotten HIV from abuse. Finally I asked (with the help of the Setswana speaking nurse) what he knew about why he was here. He said that he only knew he was sick, but had not been told anything else (his aunt confirmed this with a nod of her aunt and looked down - I think she just had no idea how to tell him). So we got out the flipchart and told him the story of the soldiers (CD4 cells) who protect the body and the bad guy who is trying to attack them. We explained that with medication to protect his soldiers and put his bad guy to sleep, he would live a long life and could do anything he wanted to do. At the end I asked if he wanted to know the name of the bad guy. He nodded. "It's called HIV." His aunt sitting next to him on the couch began to cry silently looking straight ahead so that he wouldn't see.
"What do you know about HIV?"
"That there is no cure"
"You're right. For now there is no cure, but we hope that someday there will be. Until that day if you take medications every day you will remain healthy and you can play football, go to school, etc."
He nodded. We talked for a few more minutes about how things were different today than they had been many years ago when he had gotten HIV - now that we had medications to fight it. His aunt secretly wiped her tears and looked a bit relieved that she had not been the one who had had to tell him.

A few weeks later I witnessed disclosure how it should be. I was in Mahalapye seeing a 5 year old with one of the nurse prescribers. He was thriving - growing well, about to start school in Jan and clearly a very smart and happy child. Without my asking, she took out the flipchart and began to explain, with great animation, about the soldiers of the body. When the children are very little we only tell them that they take the medications to keep the soldiers of the body strong and we add to the story each time. The little boy listened intently and answered her questions correctly. At the end I gave him a sticker which he put right in the middle of his forehead. He gave us a huge smile and headed out with his grandfather. I hope that when he reaches 14 he will remain the happy, smart, and confident child he is today.

Pictures

2009-11-22T13:20:00.000+02:00

Some random pictures from the last 2 weeks.....

The Soweto Gospel Choir

The group came to Gabs to perform. They were proceeded by two other smaller groups who were very preachy and I was beginning to feel like I had been transplanted to a bible revival in the Midwest of the US at the turn of the century. But then the Soweto Choir took the stage, and it was incredible.
They sang, they danced, there was even some acrobatics. I was mesmerized.

The Ministry of Health building in Gabs

I had to go there for my "interview" to get my official Botswana medical license. It was a formality that really consisted of my paying 30 pula (less than $5), but nevertheless managed to take all day and keep me from going to Serowe for the week (since it could only be done on Wednesdays). All of my paperwork was submitted last March and yet the interview was in November! Partly because my medical school diploma was in Latin and had to be translated in the US and resubmitted, despite the fact that all it really says is that I graduated medical school on a beautiful day in Providence....

Seems to me that the Ministry should spend less money on their gorgeous building and more money on lumbar puncture kits, viral load machines, medications, ventilators, etc, etc....

One of the patient's grandmothers whipped these out of her bag and presented them to us at the end of clinic on Tuesday. We had no idea what they were. Turns out they are Mogorwagorwana, which is a wild fruit. One of the nurses explained that you crack them open and eat the fruit inside, but not the seeds. They are quite hard and would probably make good baseballs (other than the getting hit by the bat part ;)

So we decided to try them outside. A couple of hard smacks on the brick wall and.....

It was certainly like nothing I have ever tasted before. Very mushy fruit surrounded large seeds.

It was sort of sour and sweet at the same time.

Let's just say that one piece was enough for me, the texture was very disconcerting.

The craziest sunset during a storm I have ever seen. We went to the Gabs Dam to watch the sunset and suddenly the winds picked up and we watched as a storm approached. It was really neat to stand outside and see rain, thunder, and lightening in the distance, but be completely dry. Though eventually the storm headed our way and we ended up soaked by the torrential downpour.

Showing just how strong the wind was

My birthday dinner at Mogul, a local Indian restaurant

Birthday Bots style.

The waitresses all came over to sing.

They don't have a happy birthday song in Setswana, they sing it in English.

At the end they sang "How old are you now?"

They decided I was 10, since that is how many candles there were. Fine by me ;)

The yummy chocolate cake with chocolate icing that Bri made!

It was a stellar birthday celebration, I feel so lucky to have met such great people here.

I hope that everyone has a HAPPY THANKSGIVING!

I have so many things to be thankful for this year and I will be thinking of you all this Thursday.

Patient Encounters

2009-11-20T18:10:00.005+02:00

I wrote this blog in darkness (other than the light of the computer screen, which luckily was fully charged.) The power went out just at the end of dinner. Julia, Raheel (my roommates for the week) and I were just finishing a pseudo tex-mex meal. Anyone who has ever lived with me knows that I subsist largely on bean burritos. In the States this means black beans and corn spiced with garlic, oregano and red pepper flakes and topped with cheese, salsa and avocado (if I have it), all wrapped in a large flour tortilla. Yum! I had that meal probably at least once a week for the last 10 years or so. So it was much to my dismay to find that there are no black beans and no salsa in Botswana! I thought there were no flour tortillas either; but I discovered them this past week in Gabs and felt it was a sign to try to recreate the bean burrito I have been craving for four months. I did bring some black beans back from the states, but they are dried and require much time to make so tonight it was mashed kidney beans. I even made guacamole – as there are plenty of cheap and good avocados (though lacking cilantro – another thing not available here). It was a delicious meal and just as I was finishing my last bite all the power went out. What great timing, it’s kind of exciting to be in darkness though I guess we are cheating since we have the help of numerous flashlights (aka torches).

Ok enough about dinner. Since it is dark, it seems like an appropriate time for some patient stories.

On Monday we had finished clinic and as we were walking out the nurse said “Ngaka Leah (Dr. Leah), wait there is one more” So Julia and I went back and began to see the patient. One more turned into three as 2 other patients showed up. Finally a woman and man entered the room carrying a baby. It turned out they were there for the woman’s appointment, but upon further questioning they mentioned that the baby had been referred for evaluation too. The baby was 8 months old, but the size of a newborn. Upon reviewing his chart he had not gained any weight in the last 6 mths (a time when babies have extremely rapid weight gain). He was also severely developmentally delayed as he was unable to roll over (a skill acquired at 4 mths) not to mention unable to sit or babble (6 mths skills). As we began to examine him more, we grew more worried. He was febrile and breathing faster than normal. He had very sparse hair growth, lack of fat on his buttocks, and dermatitis (all signs of significant malnutrition). He needed to be admitted and worked up for meningitis, TB, HIV, and re-fed.

Given that it was after hours, and only one medical officer covers the entire hospital, we knew that if we did not begin the work-up it would be a long time before any attention was paid to him. After bringing him to the wards we began the long process of convincing his parents that a lumbar puncture was necessary. This was a hard sell as they believed that lumbar punctures cause paralysis. Eventually the father agreed and the mother, though still not fully aligned, said that we could not say she had refused. Of course there were no lumbar puncture kits in the hospital. After much searching, a spinal needle was located as were some regular blood collection bottles which (a call to the lab confirmed) could in fact be used for spinal fluid as well. We found some sterile gloves and Bedadine and were in business. As I opened the spinal needle I realized it was like no other I had ever seen, it was more than twice as long as the baby!!!! But you gotta make due with what you have, so I went with it. All those lumbar punctures in the St. Chris ER paid off. One stick, and many mins of waiting until the fluid finally dripped to the end of the longest needle ever, revealed a nice clear fluid which turned out to be a champagne tap, as they say (no red blood cells). Two and a half hrs after seeing this "last patient" of the day, we had finally sent the rest of the blood work, ordered antibiotics, and high calorie feeds for the child and set off towards home. The next day he was already looking much improved though he still has a long way to go to catch up on growth and developmental milestones.

On Wednesday after giving a lecture on growth in Mahalapye, one of the medical officers came up to me and said that he needed me to see an outpatient and guess his age. It was an unusual request as usually patients or their parents already know their birthdays. It turned out that about 8 months ago a baby was found near the railroad tracks in town and brought to the hospital. No one knew where he came from, his name, or his birthday. He remained in the hospital for sometime (though luckily turned out to be medically fine). After much searching for his parents or extended family, he was discharged to a potential adoptive mother. But in order for the adoption paperwork to be processed he needed a birth certificate and that required a birthday. Enter the pediatrician. They wanted me to guess his age. After watching him walk and asking some other questions about his development I guessed that he was somewhere between 13-16 months. But that wasn’t good enough, they wanted a month. Okay probably 14 months. So says the potential adoptive mom that means September 2008? Yes, that sounds about right. “Okay what day?” After much back and forth trying to explain that I understood that he needed a birthday, like all the other children, but that there was really no way to say exactly what month he had been born much less what day; I told her to pick her favorite day in September. I documented my estimations and explanations and referred her to social work explaining that this was really a matter for the courts as they would have to go about creating a birth certificate.

Thursday brought us to Palapye. The "inpatient wards" there are two of the most dismal, depressing, and dirty rooms that I have seen. There were 3 patients in one very small room. They were all severely malnourished. One was a 1.5 year old girl who weighed 5.8 kg about what a 6 or 8 mth old should weigh. She had not gained weight in the month long hospital stay and finally last week they tested her for HIV and found she was positive. She had not yet been started on antiretrovirals because they were trying to work out the social situation. Finally her grandmother had agreed to take primary responsibility, had attended adherence classes and was ready to start. But then the hospital clinic said that she needed to be started at her local clinic. This sounds like a great idea, having patient's go to the clinic that is closest to their house. The problem is that these clinics are not well staffed. The one closest to her house only has a doctor on Mondays and never dispenses meds. The patients who are seen there have to wait all day to see the doctor and then make their way to the main hospital pharmacy where they wait in line again to receive their meds. Not a great set up, especially when adherence is so essential. After much discussion, and a phone call to the local clinic, the nurse there agreed to open a file for the patient and get her started on treatment that day provided the medical officer in the hospital prescribed all of the meds. So the grandmother placed the baby on her back and began the trek through the rain (it has been rainy and cool for the last 3 days), to the local clinic. The whole transaction probably took her all day, but at least the child will be started on medications that she has desperately needed for the last year and a half.

If life gives you lemons...

2009-11-11T17:24:00.001+02:00

Wonderful rainbow in Serowe I saw the whole thing, both ends!

But unfortunately could only capture one side in the photo.

The day I returned from the States I was sound asleep at a friend's house in Gabs, when I was awoken at 1 am by my security company in Serowe calling. Apparently my house (as well as three other houses in the compound) was broken into at midnight that night. The robbers must have been very disappointed because, though they searched the entire house, (while the alarm was blaring) the only electronics equipment they found was an old MP3 player. They also took some kitchen knives for good measure. It seems they were also interested in my yoga mat and some make-up as that was all packed up, ready to be taken, on my coffee table. But luckily the security company arrived and scared them away. Despite the fact that they broke into 4 houses, they did not manage to steal anything other than a cell phone from the other houses. Still it is scary to think that someone was in my house, I'm just so thankful that I wasn't there.
The next day when I returned to Serowe all of the tenants met and we came up with a list of improvements that needed to be made. We presented these to the landlord and he has actually been pretty responsive. We now have crossbars on the backs of the doors, metal plates over the door jam, better padlocks on the bugler doors, and increased lighting outside the houses. Baylor also hired a security guard and decided that I should no longer be staying there alone. So, I now have rotating roommates (other PAC docs who come for a week or a few weeks at a time). It has been nice to have company and though the house has some drawbacks, I have discovered some real positives about the location.

First, when I look out my house I see 3 trees.

They look like plain trees, but upon closer inspection at the right time of year...

I discovered MANGOES (and lemons)!!! The tree in the foreground of the top picture is a lemon tree, and the one above is a mango tree. The third tree is just a pretty purple flower tree. The mangoes are not ripe yet, but I had a delicious lemon and it looks like the mangoes might be ready soon. As mangoes are one of my favorite fruits, I definitely have developed a new level of appreciation for my house!

Second new discovery was my neighbor's garden. He lives several houses down from me and last week invited me to see his garden. In just three months he has managed to plant quite a lot. He has tons of cabbage, spinach, lettuce, tomatoes, some carrots, beets, etc. And he insisted that we take a bunch. It was the freshest head of lettuce I have ever had and made delicious salads for the rest of the week!

Finally, on a totally different topic....We managed to celebrate Halloween! It is not a holiday here, except among expats. I did not come prepared with a costume, and my mother was visiting (at the end of her two week stint in South Africa), so we needed two costumes. We decided to be each other, the subtleties of which were lost on those who did not know my mother, but we still found it fun...

Madikwe

2009-11-07T23:21:00.000+02:00

My mom found a way to come to South Africa for business - helping the Bafokeng (an ethnic group in South Africa) develop a better education system. Luckily she had weekends off and we managed to spend them together. The first weekend, I made my way to South Africa and we spent a wonderful 24 hours in Madikwe Game Reserve. The reserve is along the Botswana/South Africa border and (according to their website) home to 66 mammal species and 300 bird species. We had an incredible time. We spent the night in Mosetlha Bush Camp. It was a camp of nine tent cabins, with open sides and canvas tops. There was no electricity or running water, but they had a very ingenious toilet and shower system. You poured water from a tank into a "donkey boiler" and it came out the other end boiling hot. You then mixed the water in your bucket until it was the desired temperature before carrying it to the pulley shower. It was an amazingly refreshing shower!

But the best part of the weekend was certainly the animals! We went on two 4 hour long game drives. One from 4-8pm and the other 5:30-9:30 am! We saw tons of animals. Here are just a few highlights, for many more pictures and a few videos you can visit:
http://picasaweb.google.com/leah.scherzer/MadikweOct09?authkey=Gv1sRgCMXV2oDAi4GOEg#

Watching the giraffe get down low enough to drink was incredible

Dung Beetles!

The female lays eggs in the ball of dung and then the male has to push the ball while female rides on it.

Four lions who were part of a pride of 16 who were just resting in the shade during the heat of the day

Mother and her baby elephant (probably less than a year old)

The Best and Worst

2009-11-02T21:59:00.003+02:00

I cannot believe that it has been a month since I have written! It has been quite a busy month and with the slow internet connection in Serowe I just have not gotten a chance. But now that the Boards (aka worst test ever) are finished, (or at least I hope they are, since I really feel that I failed and we don't find out til January - not sure why scan tron takes so long), I should have more time.

The weekend before we all left to take the boards a few of us decided that we had had enough studying. So we headed to Tuli Block. It is a strip on the very Eastern part of Botswana that is known for its elephants, among other animals. It is about 2 hours from Serowe. My friends were coming up from Gaborone and I did not want to take a third car so I decided to meet them in Palapye (the town 40 km from Serowe on the main road). I was planning to take the bus, but when I discovered that it would require a taxi ride in the wrong direction to the bus station and waiting until the bus was full to leave (very unreliable when you have to be somewhere at a certain time), I decided to hitchhike. Hitchhiking is a very common method of transport in Botswana. However, as I stepped out of my house and felt rain drops I began to question my plan. But I opened up my umbrella and walked the 1 min to the tar road near my house. Just as I approched the road, a lady, who was also hitchhiking, was getting into a car. I asked if they had room for me as well. They made some minor adjustments and I climbed into the back seat with 2 other female hitchhikers and was on my way! It turns out that picking up hitchhikers is a way to make extra money as they charge the same price as the bus (8 pula, slightly over a dollar - not bad for a 30 min drive).

After meeting my friends and driving 2 hours to Tuli Block we found Oasis Lodge where we had booked rooms and a "sunset safari." The place really was an oasis with lush gardens and a nice swimming pool. If only it wasn't rainy and cold. Our guide arrived for "the safari" in a beat up pick-up truck which had been outfitted with benches which were strapped down to the flat bed. No sides and certainly no seat belts, good thing we would be going slowly. We set off and drove for about 2 hours and saw only impala (common deer like creatures which are beautiful, but not very exciting since we had seen plenty in Gaborone and the Rhino Sanctuary.

The next morning we went on a two hour walking safari. We saw plenty of dung (the dung above is from elephants), but no animals other than a giant tortoise which our guide decided to bring back to the lodge (guess he is not afraid of salmonella poisoning...) All in all a fun weekend. Despite the lack of wildlife, it was really relaxing and a much needed break from studying!

On the way home I was pulled over for speeding (first time ever in my life). Radar guns are a relatively new thing in Botswana. Police officers stand on the road with the radar gun and wave you over if they determine you are going to fast. Speed limits can be very confusing because there is often a sign when the speed limit drops as you enter a town, but often not a sign to indicate that it has gone back up even though town has ended. So on the way out of a small town they were pulling over everyone that passed. The officer instructed me to get out of the car and see how fast I was going. He showed me the radar gun which I could not read and told me I was going 95 km/hr in an 80 km/hr zone. He pointed to a police car parked under a tree about 50 feet away and told me to "go talk to the boss." The man who had gotten pulled over in front of me was getting out of the passenger side of the police car and walking back to his car. I went back to the car got my id and told my friend, Steph, what was going on. When I got to the police car, I found one cop in the driver seat and another in the back seat. They told me to get in. Tentatively I got into the passenger side. The cop in the driver seat was wearing a bomber jacket that was half zipped and reclining back in the seat, providing a good view of his chest hair. He asked me how fast I was going and I told him that his partner on the road had told me 95 km/hr.
He said "that will be 800 pula." I stared at him (that is the equivalent of 121 dollars)!
I said "but i don't have 800 pula."
"what do you do"
"I'm a doctor"
"where do you work"
"serowe"
"well that's okay then."
Guy in the back seat, "we just need your name and phone number." So I gave him my name but spelled it wrong and my number but changed one of the digits. While this transaction was occurring and (the police officer in the back was putting this info in a cell phone!), the guy in the front began to get personal.
"So are you married?" "no" (in retrospect what was I thinking, but then you are taught to be honest, especially with law enforcement officials in uniform!).
"Can I check you in Serowe?"
So I began to lie."Don't think my boyfriend will like that"
"Well I can take him"
"I don't want you to take him, I love him"
This banter went on for a few more exchanges before the guy in the back had verified that he had gotten my correct (though actually incorrect) name and phone number. Then I said "So, are we done here?" and got out of the car. I walked back to Steph and the waiting car feeling rather violated and vowing to always pay utmost attention to the speed limit signs even though they are often hard to find!

Two days later I drove back to Gabarone in order to prepare to leave for the States and the dreaded board exam. When I was about 30 km from Gabs and going 120 km/hr (the speed limit ;) I, all of the sudden, found myself in the grassy section by the side of the road spinning! I had a tire blow out. Luckily it was my back tire and so I did not go into oncoming traffic. And luckily the car is sturdy enough that it did not flip. Better yet before the car had even fully stopped a truck with 4 guys in the cab had pulled over. They ran down the embankment saying "Are you okay? We saw this happen and we weren't sure you were going to make it. Let us help you." Still shaken and not quite sure what had happened, I would have been in tears if it wasn't for the kindness of strangers. Another car stopped and 2 other guys got out and before I knew it 6 guys were changing my tire for me. Good thing because it took all 6 of them, since the jack was not able to lift the car high enough given the fact that it was on dirt. During ths process many other people stopped to see if I was okay. So when I finally drove off there were about 10 people standing and cheering. I then drove 80 km/hr back to Gabs and as each person who had stopped passed me, they waved and honked. It was truely wonderful to feel so taken care of by strangers. I now have all brand new tires, because the one that had the blow-out was a re-tread and who knows how old the other ones were even though they looked decent.

Top; there was some minor damage to the frame but my pieces were recovered from the road and put back on by my friendly mechanic.
Left: My "attempt" at a newly formed road ;)
On right my new friends survey the damage!

After all that excitement I went back to NJ to take the boards :( Despite the annoyance of the exam, it was nice to be able to spend time with family and friends (though it was very short lived.)
Lots more adventures to write about, so hopefully there will be some more blogs soon....