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....

Passover

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!!!!

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!

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

 

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!