One YEAR!

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

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

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!

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

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?

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

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....