Teen Club

 

"Teen Club Rocks"

(from the back of the Teen Club T-shirts)

Today was my first Teen Club and it rocked!  Teen Club is a chance for HIV positive teens ages 13-19 to get together each month.  There are now Teen Clubs in four cities/towns in Botswana.  The largest one is here in Gaborone with around 300 teens registered.  On the average month about 120 show up!  Since we have such a large group, the teens are divided into younger (13-15) and older (16-19) groups.  This month the older teens got to learn hip hop dancing, while the younger group had a session on "love, sex, and dating."  (Each month one of the groups does "life skills" sessions, while the other group does a fun activity and the following month the groups switch).  

The day began at 8:30, as we gathered in the clinic parking lot for icebreakers.  The fact that 120+ teenagers are willing to wake up early enough to be somewhere at 8:30 on a Saturday morning shows just how much Teen Club means to them (esp since some travel pretty far distances).  The ice breakers were led by the excellent cadre of teen leaders (teens who have been elected to help to facilitate Teen Club, they also help with planning the activities, and many were counselors at Camp Hope this year.  After the ice breakers the groups split up, with the older group going to a local school to learn hip hop and the younger group staying at the clinic.  

I was one of the facilitators for the younger group.  After an introduction, by the teen leaders, we split off into 6 small groups.  I had a group of 11 (4 boys and 7 girls) and a teen leader as a co-facilitator.  Thank god for my teen leader, who was awesome!  Many of the teens have a hard time understanding complex concepts in English and feel more comfortable speaking about tough issues in Setswana.  So she was invaluable at leading the group and bridging the language divide.  The activity was very well planned out and we facilitators had guides to help us lead the session.  We began with a map of the city and had the teens point out areas in the city where boys and girls meet.  We talked about what kinds of activities teens do in these areas and which ones were healthy or unhealthy.  In a country where billboards proclaim "Who's in your sexual network?" and where condoms are everywhere, (more on that in a later post), these teens have gotten a lot of exposure to messages about the ABCs (Abstinence, Be Faithful, Condomize).  So they were pretty quick to point out that unhealthy activities might include unprotected sex which could lead to teenage pregnancy, STIs (sexually transmitted infections), and "spreading the virus."  

Next we divided the girls and the boys and had them come up with the qualities that they would want in a boyfriend/girlfriend and then husband/wife.  The girls wanted a boyfriend/husband with "inner beauty," "one who respected them," "one who slept at home at night," (a reference to the practice of men having a "large house" and "small houses") "one who was trustworthy, caring, and a good listener."  The boys wanted a girlfriend/wife who was smart ("able to help them with homework"), playful, good at communicating, had good ideas, was a good cook, a good mother, did not cheat, was not lazy, and respectful.  We then spent some time talking about gender roles.  For example, if husbands should be expected to help out with taking care of the children.  Most girls said "well they won't even know how to change a nappy" (diaper) and the boys said "it depends on if I have been at work all day."  The teen leader and I talked a little about how roles might need to be shared esp. if both partners were working outside the home (which is pretty common here). 

We then had an exercise where we read statements and the teens had to move to one side of the room or the other to indicate whether they agreed or disagreed with the statement.  We began with "a boy should always pay for food on dates," to which only one boy agreed saying that "the man" should pay while everyone else said it should be more equal.  We moved into more difficult questions the hardest being "If a married couple of two HIV positive people wants to have a child it is okay for them to have unprotected sex."  In my group everyone disagreed with this.  One girl explained that each person has a different HIV virus so you can still pass it to the other partner even if you are both positive (very advanced understanding esp. for a 14 yr old).  Others said that the couple should adopt if they want to have children.  Obviously the powerful message of the perils of unprotected sex has reached these teens, lets just hope they practice what they preach.  At the end we joined all the other groups for a discussion of the activity.  We talked more in depth about this last difficult question and explained that it would be possible, under special circumstances, for an HIV positive couple to have an HIV-negative child, but it would be something that should be discussed with a doctor.

The activity went incredibly well.  The teens were very engaged, and though some spoke up more than others, all participated.  Teen Club is their one opportunity to be completely open about their HIV status and feelings surrounding it.  Most don't feel comfortable talking about it with any of their friends, including romantic partners, and live very secretive lives.  The burden of constantly keeping a secret can be very troublesome, so it is great that they have Teen Club where at least once a month they can be open and honest.   It did strike me though that we completely left out any mention of homosexuality.  In a country where homosexuality is illegal, it is a very taboo subject and one that unfortunately I do not think Teen Club is ready to tackle.  However, I can't help but wonder and worry for the teens who have feelings for people of the same sex.  They are already marginalized by their HIV status and being gay must be an incredibly hard extra burden.  I will have to do more investigation on this to find a way to let teens here know they can be open about all kinds of feelings with me.   

After the session wrap-up all the teens gathered for lunch and to get transport money (the Teen Club pays for their transport to and from the club to make it more accessible).  The Teen Club provides an incredibly valuable role in these teenagers life.  It runs largely on volunteers, but we do have to provide lunch and transport money.  So you may have noticed that I have added a "button" to this blog on the right hand side of the page.  It says "donate now."  If you click on this button you will transported to the Texas Children's Hospital website where you can make a secure, tax deducible donation to Teen Club.  This money also gets used to support Camp Hope.  Every dollar makes a huge difference, as for only $60 you can pay for the transport of 1 teen to Teen Club events every month for a YEAR!   If you want to read more about how much things cost look here: www.botswanateenclub.wordpress.com/donations/  So next time you are looking for a gift for someone, think about making a donation to Teen Club in their honor!

A Day in the Life

Sorry for those who are not medical, but I will try to explain some of the more medical terms....

Each day at the Botswana-Baylor Center of Clinical Excellence (or the COE, as we call it) begins at 7:30 with a prayer.  There are no appointment times; patients are just given a day to return and most show up around 7:30 (which often means they have gotten up hours earlier to travel from their village to the city).  The clinic staff (nurses, receptionists, pharmacy techs, translators, social workers, medical assistants, janitorial staff, doctors, etc.) gathers in the lobby, facing the patients, and begins to sing.  They sound like a professional choir, (for all those concerned, I sing very quietly or mouth the words to the songs I know).  Usually the songs include "Kumbaya my lord," some songs about Jesus, and songs in Setswana.   At the end, there is a prayer in Setswana.  It is a wonderful way to start the day with the songs filling the lobby, the building, and spilling out into the parking lot - giving hope  and offering support to all of our patients. 

Around 7:45 or 8 we see the first patients.  Today I saw some great success stories and some challenges.  The first patient I saw was a 16 yr old boy who came alone.  He was very energetic and doing excellent with taking all of his meds = 100% adherence!  He stopped in the middle of the visit to return a text message, and when we were done stood in the hallway with his cell phone on speaker so everyone could see how popular he was.  When I asked if he would be joining us for Teen Club this Saturday he said maybe but he had a number of things to do and wasn't sure if it would fit into his busy schedule.  His viral load is undetectable and his CD4 (cells that fight infection) are as high as person without HIV.  All that has been achieved, and he is still on first line therapy (meaning he has never become resistant to his medications - which usually happens when patients don't take their meds). 

Then there was an 8 yr old boy who had been doing very well on therapy for serveral years until 2006 when his mother stopped bringing him to clinic, and hence stopped giving him his meds.  The clinic staff tried to track him down, but to no avail.  He returned last month because he had lost a lot of weight (he weight was that of a 5 yr old, as was his height), had a chronic cough, night sweats, and fever.  He was admitted to the hospital and started on treatment for tuberculosis.  His mother, who also has HIV, had been faithfully taking her medicine (which she got at a different clinic), but had not brought him to see a doctor for three years.  She said it was because she did not have money for transport.  Today she brought back only one of the medications he had been given in July (mutivitamans and cotrimoxizole (or bactrim for those in the states) to prevent infection in those not on treatment for HIV).   His adherence on that was 76% which is not sufficient for being successful on ARVs (antiretrovirals).  Clinically he needs to start on medications, but we can't start medications if he won't take them, because he will develop resistance and be out of options.  Luckily we have an "in-reach" team and the charge nurse had a long talk with mom.  The team will go out to the house on Friday and assess the situation, do some education, and determine if the family can qualify for transportation assistance.  Hopefully, we will see him again in 2 weeks.  Hopefully by then, he and his mom will be ready to commit to treatment.

And then there was the 10 yr old severely developmental delayed boy who lives in an orphanage (both of his parents died many years ago, presumably from AIDS).  One might think that living in an orphanage would be good as far as adherence since he is taken care of by "professionals," or at least people who have received more training than most.  However, often the orphanages are understaffed and there are so many changes of caregivers that they forget to give the children their meds.  This child's viral load (amount of HIV in his body) was sky high (it has never been suppressed).  He was on "salvage" therapy - basically he has developed resistance to many of the medications available in Botswana.  So we send a resistance assay (a test to determine which drugs his HIV is resistant to and which are still options).  This test is done routinely in the states, even on patients who are on first line therapy.  But here we reserve it only for the most challenging patients, and we are lucky to be in one of the few countries in Sub-Saharan Africa where the test can be relatively easily done (though it takes at least a month).  He was again failing the therapy that had been created based on the last assay, so we had no choice but to send another resistance assay, stop all medications, and once again send the in-reach team to the orphanage to see if they could figure out the adherence problems.

Those were just 3 of the 10 patients I saw in the morning.  We finished at 1:30; I took a small break to eat a PB+J sandwich and made my way over to the main hospital for "general peds clinic."  Since there aren't many pediatricians or even family doctors in this country, most patients are seen at local clinics by nurse prescribers (kind of like Nurse Practitioners, only with less training) or medical officers (people who have completed medical school and one year of general internship (a little of each specialty) and then go into practice.)  When there is a pediatric question, they are referred to the nearest pediatrician.  As there are not any pediatric neurologists, nephrologists (kidney doctors), cardiologists, etc in the country we "general pediatricians" become instantly upgraded.  I saw several children with Cerebral Palsy and Epilepsy and managed their seizure medications.  I saw a child with steroid resistant nephrotic syndrome and started her back on cyclophosphamide (sorry non medical people - can't really explain all that).  I saw children with severe developmental delay and speech problems and sent them for hearing tests and speech therapy (luckily we do have speech therapy).  And even one that I really knew how to tackle - a 3 week old with breast buds which were already getting smaller = normal!  Basically in one day I have been upgraded from a general pediatrician just out of residency to an HIV specialist, pediatric neurologist, pediatric nephrologist, and developmental pediatrician (to name a few).  Luckily I have some of the more seasoned PAC doctors around to offer consults, but in an environment without as many labs, x-rays, and other diagnostic tests as we are used to; we are often treating blindly and following closely.

If you are still reading, and wondering how patients pay for all of this, you will be surprised to know that it is completely FREE!  The Government of Botswana (with revenue from the diamond mines (that they were smart enough to own), 10% sales tax, and 25% income tax on the weathly, pays for it all!.   This includes doctors' visits, meds, tests, and even transport to and treatment in South Africa for things, like cardiac surgery, which are not yet available here.  I say it is worth it!  And it is certainly nice not to have to fill out insurance pre-authorization forms, billing sheets, or check insurance formularies.  (Yes, you do have to check the Botswana drug list, but it is just one list for everyone and a surprisingly complete one!)

I saw a very enlightening piece on this theme from PBS (one place that allows you to watch their videos outside the US - boo to netflix, hulu, and amazon).
I recommend it to you all: http://www.pbs.org/moyers/journal/07312009/watch.html

Thinking like a Leftie

This has been quite a busy week! On Saturday I drove to Rustenberg, South Africa to meet one of the old PAC doctors and buy his car. He has been working in South Africa for the last several months, but could not sell a car from Botswana to a South African without a lot of expensive paperwork. It is a 1998 silver Honda CRV. It was not cheap by American standards (cars are really expensive here because they are all imported), but a good deal by Botswana standards. I got two of the people who work at the clinic, Bashi (right) and Michael (left), (pictured on the left with car in background, more pictures of car to come) to drive with me and we set out early on Saturday morning.

Driving here is very interesting. They drive on the "other" side of the road, which has taken a LOT of getting used to! Luckily for the first 2 weeks I was just a passenger and a pedestrian, so that gave me time to get over the unbelievably scary feeling that people are driving towards you on the wrong side of the road. By the time I actually tried my hand at driving, it wasn't as bad as I thought. Though I still have to keep saying "left, left, left" in my head. And everything is on the opposite side, the turn signal which goes the opposite way (right turn down, left turn up), the gear shift, etc. It has taken some serious reconditioning, but I am getting better. The hardest part is when there are no other cars because my instinct is still to go on the right. And of course on the bigger roads the signs say "keep left, pass right" which takes more getting used to. Luckily the car I bought is an automatic, as I have never driven stick. Learning to drive stick with the gearshift on the left is something I need to do, but can be saved for a day when driving on the left feels more natural.

The drive to Rustenberg took about 3 hrs including the border crossings which are interesting here. You park your car and get out and walk into the Botswana side of the border, fill in some paper work get passport and car transport paper stamped and then drive across to the South African side where the same process is repeated all over again! Driving back across the border with the car I bought was even more challenging as the Botswana registration had expired in May 2009. The person I bought the car from had not bothered to renew it or register it in South Africa, so the border police were not so happy. Luckily Bashi did some fast talking in Setswana and then the policeman said he was in a good mood so we could go today as long as we promised to get it registered first thing in Botswana. Apparently they can impound it at the border and wait for you to bring the proper paperwork, so I was very lucky! The registration has now been sorted. The only things left are changing the ownership and getting car insurance..."one step at a time" is my new motto here!

On Sunday a group of us climbed Kgale Hill which is the tallest hill in Gabarone and maybe even in all of Botswana, as the country is pretty flat. After about an hour of trying to find the trail, we finally found the start. (we asked several locals, but none knew since the idea of hiking is a foreign concept - why walk just to walk when you do plenty of walking on a normal day?) The picture on the left is Steph, Gelane (cheering that we have finally found the path), Agatha, and Kia. The hill is at the edge of town and on the grounds of a granite quarry (picture on right) so when you enter they display the blasting time for the week so you can avoid being on the hill when it shakes ;) Luckily the next blasting time was 3 days away so we were safe. "The path" was pretty much straight up and not really marked, though it was cleared and we were able to follow the footprints of the people before us. The end was basically rock climbing, but it was SO worth it! From the top was a 360 view of Gabarone! Best of all, there was a beautiful cloudless sky ;) This has been the case every day here, at least until rainy season comes...

At the top with the Gabarone Dam in the background

There actually was a family from Botswana at the top!
The father (who is taking the picture - I then took one of all of them together)
carried the little boy and his bottle the whole way.
This was quite a feat, since I need two hands for most of the end of the climb.

Of course, I had to get to the tippy top by climbing the last giant rock.

At the top we found this post with many cities and the distances to each. On the left (dark because it was taken into the sun - sorry) is Agatha, Steph, Kia and Gelane. On the right is me with a close up of the NYC post. 12,541 km (7,794 for those who like miles) from home, and still video chat can make it seem like people are right here!

"Obama Land"

On Tuesday I had my first glimpse of what will soon be my new home. The Botswana-Baylor Children's Center of Clinical Excellence is located in Gabarone (the capital of Botswana). The goal of our program is "capacity building" aka training local doctors to take over our jobs. Much of this work has been done in Gabarone and now we are spreading the training to surrounding regions. There is already a PAC doctor based in Francistown and each week doctors from our center go to surrounding clinics to train, precept, and troubleshoot. But, as you can see from the map below, it is hard to reach all of the country from Gabarone. The program decided that they wanted to place a PAC doctor permanently in Serowe and hopefully eventually in Maun. I have volunteered to go to Serowe. It is about 320 km from Gabarone (about 3 hours away).
Serowe is the town where the first, and also the current (son of the first), President of Botswana is from. It is also the adopted home of Bessie Head (famous writer whose books include Serowe: Village of the Rain Wind - on my "after the boards reading list")

I went to tour Serowe with Dr. Joel who has been going to Serowe for a few days each month to begin the training at their clinic and assist with care of their pediatric patients. The drive to Serowe proved to be quite interesting. We passed the Tropic of Capricorn and stopped for a photo-op, saw tons of cattle and goats, drove alongside the Botswana railroad (which now only carries freight), and talked all about Botswana politics, American politics, the two health care systems etc. I also learned a lot about the residency programs in Ireland as that is where Dr. Joel did his training. The biggest surprise came on the road between Mahalapye and Palapye when we had a tire blow out. The tire was reduced to shreds! Luckily people in Botswana are very friendly and helpful and a nice man stopped and helped us change the tire. It is very fortunate that Dr. Joel is such a good driver and that people are so helpful because the rest stops look like this...
There is usually a sign with a picture of a tree on it and underneath is written "1 km" with an arrow. Then 1 km later will be the sign pointing to the tree. I saw many of these signs and kept wondering why there were signs pointing to trees. Finally I asked Dr. Joel and he told me that they are rest stops. Under the tree is a small table with a bench and people can pull off the road to rest under the tree and eat (especially good in the summer when it is very hot ;)

Finally we arrived in Serowe! The hospital is magnificent. It is about 1 yr old. The government of Botswana built 5 district hospitals last year, (Serowe was one of them). Their plan is that if they build the infrastructure then the doctors will be more willing to come and work there. Botswana started a medical school this year so in 4 yrs there will be a new cadre of doctors and they will have wonderful facilities. However, for the time being, the hospitals are not very full and relying on help from foreign doctors.
Above is the second floor of the lobby. To the left the view of the front of the hospital. And on the right one of the patient floors. It is truly a gorgeous facility. There is currently one pediatrician who is from Cuba. His English is really not very good, so I will get to practice my Spanish after all ;) Everyone was very excited to meet me and hear that I would be working with them. Many said "when are you starting? Tomorrow?" I will likely be spending some of my time at this hospital and some of my time doing outreach to surrounding sites. I will move once my house is ready. We looked at a couple of places and I found one that is suitable. It just needs a couple of adjustments, as the last tenants just moved out, and it needs a security system. So depending on how fast things happen, (which is not very fast here), I will likely be moving in a few weeks. (Dr. Joel took the pictures so they will follow shortly).

You are probably all wondering about the title of this post (that is if you are still reading since it is quite lengthy ;) Well on Wednesday morning I was introduced to all of the medical officers, head nurses, and administrators of the hospital. Dr. Joel said I was a pediatrician from the United States. The superintendent of the hospital said "You are most welcome from Obama land!" It is so nice to finally have a president that I (and everyone here) is proud of ;)

Camp Hope

As mentioned in my last post, this week was Camp Hope. It is a camp for children who are seen at the Botswana-Baylor Children's Center (which means that they all have HIV). 50 children were chosen for the camp. Those chosen were those who are having problems with adherence (ie missing lots of doses of their meds), those who have particularly difficult social situations (ie lack of support, orphaned, etc), those having problems dealing with the stigma associated with HIV, and some children who just really wanted to come. They ranged in age from 9-12 and were mostly from the area surrounding Gaborone, though some traveled much further for the chance to come. For many it was their first time away from home and the first time they were able to be carefree children. The camp was held at a local boarding school.

The medication sorting table
Dr. Joel (a Pediatrican from Botswana who works at the COE),
Me, Bri, Julia (both are fellow PAC docs),
Kia, with her back to the camera, is a visiting med/peds intern from the states

The children arrived on Sunday and the first major task was collecting and sorting all of their meds so that we could properly dispense them throughout the camp. This was not an easy task, as most of the children are on at least three separate medications which mostly have to be taken morning and night.

Here I am hard at work sorting meds into AM and PM doses

The medication sorting process made us all realize just how much of a burden these medications are. Some have to be taken with food, others on an empty stomach, some need refrigeration, and they all have to be taken around the same time each day. Most importantly one can really not afford to miss any doses. For other illness (like high blood pressure for example), taking around 80% of one's medication is relatively good and a patient will likely have decent outcomes. However, for HIV, studies have shown that resistance to the medication can develop when people miss more than 2 doses out of 60 doses in the month (aka less than 95% adherence)! And mostly we are not talking about one pill a day. Most patients have to take around 6 or more pills in a day! There is good news though, as many newer combination pills are becoming available. There is now one pill (combining three drugs in one) that can be taken once a day. However, only certain patients can take this medication, and though it has just recently become available in Botswana, it is not available in most of the rest of Sub-Saharan Africa. So on the left is a daily dose of medications for one of the children at camp. If you look closely you will see the pills in the bags and notice that many of them are quite large.

Enough about the medications, camp was really about having fun! I wish I could post pictures of the campers having a truly great time, but we were not allowed to take any pictures of campers in order to protect their privacy. Many of them have not disclosed their status to anyone, including some family members. As a result, no pictures were allowed except for the designated photographer who took pictures only of those children whose parents had signed photo consent for photos to be taken and used only for official purposes. But take my word for it, the campers had an amazing time! They danced, sang, played sports, had cooking classes, did art projects, and even got to go on a game drive. We even made smores (though they don't have graham crackers here, so we made them on "biscuits" aka cookies ;) It was so amazing to see them all laughing and playing and just getting to be children. At the end of camp (today) there was a slide show for the parents and a few of the children spoke. One said that many of the children had come to camp with low self esteem and now it was high. One said that she was so sad to "graduate" from camp because she had made so many great friends and wished she could just stay at camp. It was truly moving to watch the children this week and to realize that without Anti-Retroviral medications (aka HIV drugs) these children would not be alive. However, with the medications, (though burdensome), you would never know that they had HIV.

Orientation

This past week as been orientation! We have spent most of our time in the center's board room, below ;)
We have learned all about Botswana's national guidelines for HIV care, how the center runs, and have even had time for a Setswana lesson! Setswana is very hard to learn as many of the words have multiply meanings and pronunciation is difficult. But I can now do basic greetings in Setswana.
I spent yesterday working in the clinic. It was very busy. Most of the patients were doing incredibly well with undetectable viral loads on medicines. I saw some complex patients as well. One was an 18 yr old male who was severely mentally challenged and very confused about his medications. We are very fortunate to have a psychologist, social workers, and even an "inreach" team (social worker/nurse who go to patient's houses to assess the home environment) to help with these complex social situations. They are working very hard with him and his family to remedy the situation, but much like the U.S. these situations are incredibly hard to solve.
Today is the beginning of Camp Hope. A one week long sleep away camp for children who are HIV positive. I'm looking forward to being a part of the camp and hope that will be covered in the next post ;)

Gabarone Game Reserve

On Friday we visited the Gabarone Game Reserve. It is a protected area about 5 min from where we are staying in Gabs. You can drive your own vehicle around the park and see what you see. We saw two zebras, ostriches, warthogs, bush bucks, kudus, monkeys, and gemsboks (to name a few;). It was so neat to see so many animals 5 mins from our house, and they were so close to us! This was only a brief taste of what a true safari will be like, I can't wait!!!

Dumela

Dumela from Botswana!!!
Dumela means hello in Setswana, and it is a beautiful sounding word. I have heard it many times in the last 5 days. I arrived in Botswana on Tuesday July 28th at around 4 pm after well more than 24 hours of traveling. The trip went very smoothly and amazingly all of my baggage arrived without any problems at the Gabarone airport. The airport is pretty small, only one baggage claim area. Here is one of my first views of Gabarone. It is a picture of me and Julia (a fellow PAC doctor) on the runway at the airport with our small prop jet in the background.


I am currently staying in Gabarone, but I will be moving to a town called Serowe in a few weeks. Gabarone (or Gabs as everyone calls it) is a very modern city. There are several movie theaters here which are showing Harry Potter, Bruno, etc (basically the same movies that are currently out in the US). Already I have eaten pizza, Italian, Indian, Chinese, and today I even found veggie burgers for sale!!!! I hear that Serowe is much more rural, so I'm getting my fill of these luxuries now. However, it is only a 3 hr drive away, so hopefully I will be able to come and stock up periodically. For now I am living in a wonderful house with three bedrooms. However, only one room has a heater and since it is freezing, (by that I mean 40-50 F at night, as it is winter here) my temporary roommate (Steph) and I are sharing a room.


On the left is a picture of the front of the house. It is in a complex with several other PAC doctors and other families. We do not have internet in the house yet (they are working on it but it may take some time, which is why I have not blogged before this, and why this blog is so long!).

The Center of Excellence in Gabarone is pictured above. It is a very up to date clinic, they even have ELECTRONIC MEDICAL RECORDS!!! There will be more pictures and details of the clinic to follow, as I officially start there next week.