The Campaign

The HIV prevention campaign in Botswana is quite extensive.  Every place you go there are signs, billboards, etc about HIV. The signs are much more explicit than education campaigns I have seen in the States.  Here are just a few examples.  The one above is part of the "break the chain" campaign.  There are billboards all over the city, highways, etc that state "Who's in your sexual network?" Some also say "break the chain" others leave it up to the individual to make the connection.

This sign is in the Serowe town center, right next to the bar.

If you look closely, you will notice that the wall of the bar is covered in "lovers" ads (a condom company)

A condom dispenser outside one of the public bathrooms at a local restaurant.

Unfortunately they are usually empty.

Even the inside of the moving truck that moved my furniture to Serowe was coverred in HIV prevention ads. The one of the inside of the truck is hard to read but says "Think before you act. Be wise Condomise"
Truckers are one of the highest risk groups, so this seems like a good place for ads.

Ads like this one for the controversial circumcision campaign are all over the city on billboards and buses.

They are trying to push the idea of personal accountability

One of the local free testing centers in Serowe

Free condoms were sitting on the nightstand of the hotel where I stayed on my first outreach trip to Serowe.

All of these seem like good ideas.  The unfortunate part is these campaigns are not working too well.  Condom use is still at only around 60% (though I guess that is higher than it was at the beginning of the epidemic, it has not incresed in recent years) and the prevalence of HIV in Botswana has increased slightly in the last year (0.5%).  It has decreased since the beginning of the epidemic but recently has gone up.  Getting people to change their behaviors is probably the hardest task in public health, but at least they are trying.  And putting ads in peoples' faces does force them to think and talk about HIV at least a little more than before.

Today is Botswana Day/Independence Day, 43 years since Botswana became an independent nation (luckily the diamonds were discovered after independence ;)  So Happy Independence Botswana!

AIDS Impact

The Gabarone Iinternational Confernce Center at 

The Grand Palm Hotel (where conference was held)

Quite a nice facility

There were even peacocks on the grounds of the hotel!

This past Thursday and Friday I was lucky enough to be able to attend the AIDS Impact Conference in Gaborone.  It was an international 4 day conference where doctors, psychologists, researchers, economists, etc presented their research on different aspects of HIV and AIDS.  Much of the conference focused on the social and economic impact of AIDS.  It was quite interesting. Though some was disturbing.  For example, there was a study done in Botswana to see which groups were more likely to have multiple concurrent sexual partners.  (Public education about reducing the number of sexual partners and "breaking the chain of HIV" is one of the major areas being targeted as a prevention strategy.)  The study found that both women and men who were more educated and richer were more likely to have multiple concurrent sexual partners (defined as more 2 different people in the last month) when compared to their less educated poorer counterparts.  This is a bit disheartening because one would think that those who are more educated about the risks might be more likely to avoid risky behaviors.

There was also a big discussion of the role of circumcision in prevention of HIV.  Three different studies done in Africa have shown that circumcised males are less likely  to contract HIV when compared to their uncircumcised counterparts.  So there is now a big campaign in Botswana to circumcise men.   The problem is that circumcision is not as effective as condoms and does not provide any reduction in risk of transmission to women.  Some men after getting circumcised have a false sense of security and believe that they have a "natural condom."  However, if circumcision provides some protection maybe it is better than nothing since condom usage is only around 60% (despite widespread campaigns - more on that in a later post).   I find it to be a very interesting debate and can see both sides of the argument.

I attended a motivational interviewing workshop which will be quite handy (I hope) in trying to get through to teenagers.  There was also much discussion on the economic aspects of the epidemic and how by focusing only on HIV we have neglected so many other things.  On presenter told the story of people in Tanzania who after testing negative for HIV were upset.  When asked why, they responded that they had no food and wished they were positive because HIV positive people were eligible for food baskets!  What have we done?  Unfortunately there was not as much about where to go from here as I would have liked, but on the whole a very enlightening two days.  And there is hope from Thailand, with the first vaccine to show any benefit.  Still a long way to go but progress!

Here are some random pictures of the last week.

  Me and Julia in garden at the Serowe Hotel

Hanging out with some new Serowe friends

Me, Lincoln (Peace Corps volunteer), Shamu (medical officer from Zimbabwe), Joanna and Danny (doctors from Cuba), Louisa (doctor from Sierra Leone who has had a private practice in Serowe for many years) and Daniel (science teacher from Zimbabwe who studied in Cuba and has been teaching in Botswana for many years).  Quite a diverse group!

This is a picture of a girl I met in the center of Serowe who came up to me and said that she wanted to be my friend.  She said that she wanted to live in my house, I told her that was not going to happen.  Then she begged me to take her picture and send it to my friends in the States. So here it is.  (She is wearing an interesting shirt - not quite sure of the full meaning)

L'Shana Tova (Happy New Year) to all Jews reading this (and anyone else who wants to celebrate the Jewish New Year).  I hope that this year brings much happiness, hope, wisdom, and change to all the corners of the earth!

Disparities

This past week has been quite busy.  I worked at 2 different hospitals and one local health clinic.  The disparities in the care available to patients in the village compared to what is available in Gabarone are striking (not to mention when you compare it to The States!).  Botswana actually has quite a good preventative care model in theory.  Every village has some sort of health facility.  The smallest villages have mobile health posts that are staffed once a week or so by a nurse who travels to the area and does his/her best to provide basic services.  Larger areas have health clinics that are mostly staffed by nurses but medical officers visit about once/week.  Then there are district hospitals that can provide basic hospitalizations and procedures like c-sections.  Finally there are larger "referral" hospitals.  The problem is staffing and transportation.  The clinics are staffed largely by nurses who try their best and refer when things get more complex, but there are no x-rays or lab tests available at the clinics and getting patients to go to the hospital for these services or to be seen by a doctor is hard.  Also when patients are very sick at the local clinics the transportation to the referral hospitals can take too long and many don't make it. 

Even at the district hospitals resources are very scarce.  When I was in Palapye (the town about 20 min from Serowe) last week I saw a 10 year old with asthma who was breathing 70 times/min and really struggling for every breath.  She was in the "paediatric (they use the British spelling here) ward" which consisted of 2 small rooms (about the size of a standard single patient room in the states) each with 4 patients (one of the patients was sleeping on a mattress on the floor and all of the patients' mothers were with them - it was quite crowded.  There was no oxygen in the room and there was no nebulizer machine to give her albuterol which she so despirately needed.  As the "Paediatric Specialist" they wanted my advice.  Well, I thought she needed albuterol, oxygen, steroids, IV fluids, maybe even intubation the way she was breathing, but what was available?  The nurses were actually great once I explained that she was incredibly sick, but could get better with the right medications.  They found an albuterol pump and even a spacer which had been used by another patient, but we cleaned it!  One of them went and got an oxygen tank (of course, then we had to look for a face mask or nasal cannula - there were none to be found).  After about an hour (during which the mother was giving the child 2 puffs of the inhaler every 15 mins) a nebulizer machine was found! We (atcually they) even figured out how to plug it into the wall socket without an adaptor (all the wall sockets here have 3 square plugs and all the appliances have 3 round ones or 2 long ones, so you always need an adaptor for everything.  Unless you stick a pen into the top square plug and jam the two long ones into the bottom holes - or something like that - I use adaptors (don't worry mom and dad ;)).  We did not have a face mask so we rigged up the albuterol, so that the mother could sit with it under the child's mouth.  Then I suggested giving her IV fluids and a dose of magnesium.  There is no way to drip fluids here, and magnesium is supposed to be a slow infusion over 15 min.  So we calculted the amount, mixed it in a syringe and one of the nurses pushed in 1 ml every min for 15 min.  I felt kind of like McIvor.  But several hours later the patient was already sounding better and the next day she was home!

Not every story is as cheery, of course.  In Palapye almost every child I saw in clinic on Wednesday had a detectable viral load.  Basically when you are on treatment for HIV your viral load should be undectable.  If it is detectable then usually you are not taking the medications or have developed resistance (most often from a previous episode of poor adherence).  These children are largely failing because they are not taking the medications and mostly it is because they have no social supports.  Many are orphans living with relatives or in homes for orphans and no one ensures that they take their medications every day.  In Gabarone we have a psychologist and a social worker to help patients and families through these issues.  In the smaller villages there is sometimes a social worker, but usually it is one or two people for the entire hospital and there is not much they can do to change the home situation for many of these children.  Also in the district hospitals it is harder to get labs tests done and returned.  Viral loads have to be sent out and resistance assays (tests to see which medications the patient has developed resistance to.  We use this only when they are failing second line therapy to try and figure out a salvage regimen for them as third line) are taken to Gabarone one day a week.  On Wednesday the CD4 machine was down so none of the labs were being drawn.  All of this means that many of the children I saw had been failing for months and we were still unable to select a regimen that might work for them. 

The local clinic was even harder.  Basically the clinics are a collection of trailers.  The Infectious Disease Clinic (aka the HIV clinic but no one wants to call it that) is usually the last trailer in the back of the clinic.  Yesterday the one computer at the clinic (which provides lab results) was not working, so it was hard to figure out how to manage the patients with no results.  There are no appointment times at any of these clinics so all the patients show up before 7:30 and try to be first.  They end up spending all day waiting to see the doctor, then they have to wait in line again for a nurse to draw blood if they need it (to be sent to the hospital) and finally they have to go to the hospital to wait again in the pharmacy line and get thier ARV (anti-retroviral) medications.  So a visit to the doctor is at least a one day affair - more if you wait until the next day to go and get your medications filled.  It is no wonder that adherence is an issue.  And despite all this the vast majority of people are incredibly adherent to their medications (studies have shown that people in Africa are more adherent than those in the States.  I think it may be because everyone here knows someone who died of AIDS and they know that taking the medications is the only way to survive.) 

These are some views of one of the local clinics.  On the left is the waiting room with the 2 consulting rooms on either side.  Picture this filled with 70+ people waiting to see the doctor!  On the right is a bad picture of the trailers that make up the clinic.  (I was trying to be inconspicuous)

I don't want this post to be a total downer so I thought I would end with a picture of the beautiful sunset that I can see from my house every night.  The stars are also incredible. 

And here's one of the horses that often hang out right in front of our gate.  On some days there are donkeys too.  I'm not sure who they belong to, but they seem to know thier way home at night. 

PHOTOS

Sorry for the random organization here but I can't figure out how to get them in a better order right now and internet cafe closes at 11:30 on Saturdays.....

My house in Serowe

There are 5 others just like in a row, I have the first one.

3 bedrooms, a bathroom, kitchen and living room,

quite spacious for one person (but plenty of rooms for visitors, hint, hint)

Classic bird on rhino picture

They were so intent on eating their grass, they did not seem to notice us even though we were about 10 feet away!  A good thing since they can be dangerous if mad!

(Don't think this one needs a caption you all know what this is ;)

My living room

The kitchen.  On the wall by the circuit board is the electricity unit.  I have to go and buy a electricity for the month and then enter a code in the box, which then supplies electrcity for the alloted killowatt hours.

A sunset view of the village from the top of a hill near the town center. 

It actually goes on for quite a distance.

Goats (and cows) are everywhere here.  They are definitely free range!  Here are some walking across the main road in the town center.  Apparently they all belong to someone and they find their way back to their respective farms (I'm not sure how).

"The Village"

I have moved to the “village.”  Serowe is a village of about 70,000 (a town by most US standards, but here they call pretty much everything that is not one of the two cities a village).  As I mentioned previously, it was the home of the first ever president of Botswana and birthplace of the current president Ian Khama (the first president’s son).  As such, it is a village that is well looked after which is probably one of the reasons that the large “referral” hospital was built here.  You can see pictures and description of the hospital here.
I officially moved here last September 1st.  It has been an adjustment.  Gabarone is a large city with many restaurants, movie theaters, etc.  In Serowe there is not as much of a recreational life.  However, there are high quality supermarkets, plenty of furniture (I’m not sure who buys things there as furniture is pretty darn expensive) and clothing shops, gas stations, a few hotels with restaurants, and tons of bars.  However, the internet infrastructure is lagging behind, there are many more dirt roads, there are many fewer foreigners, many more bugs and other critters, and very few doctors.  I am trying to get internet set up in my house which has been a process.  Though I live right next to the post office which has internet, (they even have an internet cafe but it closes at 4 pm), the Botswana Telecommunications Company says that all the lines are full (whatever that means) so there is no room for me to have a landline or internet.  I am working on looking into cell phone based satellite internet options, but until then might be hard to get pictures on the blog (there are so many to upload but they will come with time ;)  Despite the frustrations it feels good to finally fully unpack and feel more settled. 
I am working at many different sites in the area.  The hospital which is very nice, was built a bit outside of the main village and in a country where most people do not have cars this presents a challenge for the patients.  Many of them are continuing to go to the smaller local health clinics for care as they are more convenient.  Up until now, our program has provided support for two days each month to the main hospital’s clinic but we have not been helping at the smaller local sites.  I will be trying to roll out the support.  However, this is a challenge as there are no maps, no street names, and the clinics operate on a skeleton crew (often there is only a doctor once a week).  With the help of some locals, I have located two of the clinics and though there was no doctor there when I found them last week; I now know which days doctors will be there.  In addition to Serowe, I will also be working in two surrounding villages (Palaype (about 30 min away) and Mahalapye(about 1.5 hr away).  Both of these villages have larger hospitals and surrounding clinics as well, so I will be trying to work out a schedule that can provide support to as many as possible. 

The good news is that without internet or much nightlife, I have had plenty of time to study for the Boards.  However, last Friday I did manage to meet up with Lincoln (a Peace Corps volunteer stationed in Serowe) and he gave me a great tour of the town and introduced me to the friends he has made in his year here.  Many of his friends are from Britain and South Africa, so I got the beginning lesson on how to watch cricket (which was playing on the TV at the hotel restaurant/bar where we hung out).  I’m afraid it will take many more lessons before I have any idea what is going on (as it is I was just starting to understand American football when I left the States).  I have also made friends with some of the Cuban doctors here so there is a possibility of Salsa lessons and improving my Spanish….

Last Saturday (after I studied in the morning), Julia and Raheel came up from Gabs and we went to the Khama Rhino Sanctuary (only about 30 min from my new house) for the afternoon.  It was incredible.  The Sanctuary was set up in 1989 after it was recognized that the Rhino population in Botswana was becoming extinct.  The first four rhinos arrived in 1993 and since then a few more have been relocated to the Sanctuary and many more have been born.  There are now 34 white rhinos and 3 black rhinos.  They roam in an area that is 4,300 hectares (10,625 acres) and some have been relocated to other national parks in Botswana as the land can only support about 40 or so.  It has been quite a successful project and the rhinos continue to reproduce.  At the Sanctuary one can drive around in his/her own car alone or with a guide or can go on a game drive.  We elected to get a guide but take our own car so we would be free to spend as much time as we desired.  Our guide “Mr. T.” was a wealth of knowledge and of course excellent at spotting the animals.  We saw 12 of the white rhinos including 2 babies, giraffes, a zebra, wildebeest, kudu, springboks, ostriches, warthogs, and many different species of birds.  The black rhinos did not feel like showing their faces but we got up close and personal with a few of the white rhinos.  It was a great day and I know I will be back to visit many times in the future!