Nigeria

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

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

  

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

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

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













 

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

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

Gelane and an adorable baby!

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

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

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

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

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

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

A busy Saturday

 

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

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

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

There was also a hired group of traditional dancers

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

Plenty of cute children were present

One YEAR!

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).