Pediatrician In Botswana

Welcome!

2009-07-11T01:30:00.000-07:00

Houston Network Meeting Award Dinner: (L to R) me, Floriza, Andres, Prof Anabwani, Refilwe, Lindsay, Gadzi, Paul, Grace, Ed, and Sarah.

This blog piggybacks on a previous site I have been keeping since 2006-- http://www.pediatrician-in-swaziland.blogspot.com/.

As the address line suggests, I am now working in Botswana (still for the Baylor International Pediatric AIDS Intiative). While here, I will be wrapping up my Swazi blog while building this one.

Like my previous entries, the postings to this site will be roughly divided into several categories, including “Patient encounters”, “Cultural encounters”, “Botswana destinations”, and “References” (including media stories, useful websites, etc.).

I hope you enjoy it.

Selected quote #6: Where credit is due.

2009-07-11T01:27:00.000-07:00

"President George W. Bush and First Lady Laura Bush did not turn away in Africa’s time of need. They chose decisive action, and millions of African men, women and children have been the beneficiaries.”

With these words, BIPAI President Dr. Mark Kline awarded the Bush's the 2009 BIPAI Leadership Award. Past recipients of the Leadership Award include Botswana President Festus Mogae, Duke University Professor and PMTCT trailblazer Catherine Wilfert, United Nations Envoy for AIDS in Africa Stephen Lewis and Bristol-Myers Squibb Foundation President John Damonti.

(Press release at: http://bayloraids.org/newsreleases/release52.pdf)

Telling true stories - A patient encounter

2009-07-11T00:43:00.000-07:00

Tsothle looked intently at the cartoon figures, smiling. Occasionally she nodded. At one moment, she pointed and, raising her eyebrows, asked a question that I did not understand. Gloria, the Setwsana-speaking nurse who was discussing the pictures with her, answered, and she said “Oh. Okay,” nodding again.

The cartoon images shown to her were of HIV and how it works in the body. Though this child was nearly thirteen, she had no idea. She has been on ARVs for over ten years now, and nobody had ever told her why, for her family wished to keep it a secret and those providing her with the medicines assented.

This past week Tsothle had her first visit to the Baylor Centre, and as I was about to walk into the exam room, one of our nurses pulled me into another room to warn about Tsothle’s delayed disclosure status.

“Disclosure status”, as you might guess, refers to how much we (the guardians and/or health professionals) tell a child about something, in this case HIV. Disclosure terrifies us so much that we (family and health care providers alike) often lie to children, or simply tell them nothing. We do this because we want to protect the child, and of course protect ourselves from discomfort, guilt, and whatever other feelings come from telling an innocent young human being that they were born carrying a value-laden disease that, if not kept at bay by treatment, can maim and kill.

Tsothle came with a pressed, navy school uniform, intelligent eyes, a kind disposition, and ten years—2-3 centimeters—of worn-out medical records, mostly handwritten in MD hieroglyphics, many pages cloth-like from the years of crumpling and the residue of several hundred hands. Along with her medical archive, Tsothle came with a level of HIV in her blood that told me that she was either not taking her meds or that the virus was resistant to them (ie not at bay).

I looked for evidence to explain the high levels of HIV in her body, and found a two-year old lab result that told me that she was resistant to some first-line ARVs in 2007. Given that HIV medicines usually only stop working when not taken appropriately, I began to worry that Tsothle was now resistant to the second line of medicines that she had been taking over the past 2 years because she had not been taking them either.

I looked for quantitative evidence regarding her adherence to medication, only to find that it was never monitored. “Have you ever had your pills counted?” I asked.

“No.” Tsothle said.

“Not once?” Both mother and daughter nodded in confirmation. (Note: Here in Botswana, saying or indicating yes confirms a negative. Example: Q: “So you don’t want fries with that?” A: “Yes.” Meaning: No fries.)

The good thing about pill counts is that, unless manipulated by a mathematically-minded child or caregiver, they provide quantitative evidence of a behavior (or lack thereof). When it comes to qualitatively assessing desirable/undesirable behavior (asking, for example), people often distort the truth.

“Have you been missing doses?” I asked Tsothle.

“Yes.”

“So you are not taking all of your medicines?”

“Yes.”

“Thank you for being honest,” I told her. A heaviness crept over me as I realized that Tsothle was about to learn that several people close to her had not been so truthful.

I asked Gloria if she would step outside and discuss the advantages of disclosure with the mother, which she did while I examined the child and asked her about school. The mother, hearing the advantages of our simple, step-wise explanatory process, immediately agreed that we should start telling Tsothle the truth.

And so Grace began telling the story about the soldiers that protect the body, the “bad guys” who wish to do the soldiers harm, and the medicines that give the soldiers stronger armor and make the bad guys sleepy. While the cartoons that we use to tell the story do not resemble CD4 cells or the ice-cream cone-shaped human immunodeficiency virus, the role of the protagonists and antagonists are clear. We avoid scientific names, but we do tell the child the truth.

After Gloria finished, Tsothle asked if she could take a dose of her ARVs now.

“Twice a day is best,” Gloria said.

“Yes,” I confirmed. “Twice a day only…Come back in two weeks and let’s count your medicines and check to make sure those bad guys are asleep.”

“They will be,” Tsothle said.

The mother smiled, her face wearing the kind, thankful, relieved expression that makes this work seem like anything but.

Botswana destinations #8: The Khutse Game Reserve

2009-07-07T00:47:00.000-07:00

Khutse means the place where you kneel down to drink. The Khutse Game Reserve is situated in the Southern Kalahari. Once a land of rivers , the "KGR" is now laced with dry river valleys and pans. A “pan” is formed where water pools and evaporates. The salt pans of KGR therefore may have been destined to be lakes or ponds but for the fact that they had the misfortune of being born in the Kalaghari desert.

The extensive pan system within Khutse provides an important habitat where herbivores graze on the mineral-rich grasses of the pans and so-called super-predators (lion, cheetah and leopard) graze on the herbivores. Recently, boreholes have been established at certain points within the reserve in order to fill small watering holes year-round. Recently, I camped a kilometer away from one of these watering holes.

There is something exhilerating about waking in the dark to the sound of lions roaring. It is the feeling of voluntarily suspending one’s coveted position at the top of the food chain. Kind of like scuba diving with sharks, though the cage used by underwater adventurers offers more protection than a nylon tent. Fences between me and roaring cats were none (though it I had brought a cage I would have gladly locked myself in it). Besides fortuitous sightings of both lions and a leopard from the relative safety of a 4x4, there were no altercations with deadly felines, though there was rumor of a [non-human] kill several hundred meters (or so) from where we slept.

In addition to lions, we saw giraffe, gemsbok, eland (I think), kudu, wildebeest, springbok, steenbok, and several other non-specific herbivores falling into the category of prey-deer.

The reserve is a good 4-5 hour drive from Gabs, but worth the trip. Keep your campfire steaks well-sealed while you sleep...or dine vegetarian for the weekend, though it seems that this lifestyle choice has not helped our fellow meat-averse mammals in the vicinity.

Photo series: The Nile

2009-06-29T23:00:00.000-07:00

Nile river rafting trip. (I am front left of raft, next to Dr. Paul Mullan, in green.) Story to follow.

Botswana destination #7: The Botswana-Baylor Children’s Clinical Centre of Excellence

2009-06-25T23:41:00.000-07:00

The Botswana-Baylor COE

This is where I work. The Botswana-Baylor Children's Clinical Center of Excellence (COE) was opened and officially dedicated by His Excellency Mr. Festus Mogae, President of the Republic of Botswana, on June 20, 2003. The facility was the first of its kind on the African continent (since followed by others in Uganda, Lesotho, Swaziland (where I used to work), Malawi, and soon Tanzania. The Botswana clinic is one of the largest providers of highly active antiretroviral therapy (HAART) for children in Africa. Since its inception, over 2,000 children have been initiated on HAART by Botswana-Baylor staff.

As part of the Government's National ARV Program known as MASA (literally, "new dawn"), we provide comprehensive treatment and care services to all Batswana children, free of charge. The clinical team consists of nurses, doctors, social workers, a psychologist, translators, M&E/data officers, and others.

Thanks to the Pediatric AIDS Corps Program, Baylor supports over half of the paediatric specialists in the country.

My office is on the second floor. From there, I help to coordinate the COE’s programs, which in addition to direct provision of ARV care include: nationwide clinical mentorship and didactic training in pediatric HIV prevention care and treatment (for health professionals as well as laypersons); pediatric TB/HIV diagnostic and treatment support; client home visits; adolescent-specific services; technical support for several areas of pediatric sub-specialty care; and participation in national guideline/policy advisory committees (with foci ranging from TB/HIV to national research protocols, IMCI to HIV prevention).

These programs enjoy funding support from UNICEF, the CDC, the Botswana MoH, and others. If you want to learn more, contact me or, better still, drop on by for a visit.

Photo series: We wish you well

2009-06-20T23:00:00.000-07:00

L to R: Dwight (leaving for ID fellowship at Duke), Norma (returning to her ID faculty position in Houston), Paul (ER fellowship at Texas Children's Hospital, and Edwin (Doctorate of Public Health Program in Houston)

You will be missed. Come back soon.

Selected quote #5: "I am so happy.”

2009-06-20T05:32:00.000-07:00

A man came up to me earlier this week in the Princess Marina Hosptial corridor and said this. I did not know him. I could see that the man was indeed happy. Still, I was caught a bit off guard, and I paused for a second or two before responding.

“Why are you happy?” I asked.

"Because I am just from the lab. My CD4 count is high. I am strong."

"Then I am also happy," I said.

And I was. Very.

Selected quote #4 "You are growing!"

2009-06-15T05:37:00.000-07:00

Gloria, one of our Botswana nurses, excitedly told me this upon finding out that it was my birthday today.

While I certainly hope that this is the case, it immediately brought to mind a short speech given in our waiting room this morning. After the morning song, one of the mothers spontaneously stood to thank the Baylor staff for helping Botswana's children remain healthy despite having been born with HIV. Surrounding her, there were literally dozens of healthy children, children who, thanks to ARVs, now have the chance to grow up. Just a few years back, there was no medicine, and many did not live. Growing older alongside these children is the most wonderful birthday present imaginable.

Botswana destinations #5 & #6: Wimpy and Steers

2009-06-13T06:53:00.000-07:00

Image: http://www.sonoma.edu

Want a hamburger? Wimpy and Steers are the fast food burger leaders in these parts (though, believe it or not, there is a McDonalds three hours east of here in South Africa). Wimpy, named I suppose after Popeye’s burger-loving sidekick, has good milkshakes and coffee, and they serve a cheap and relatively fast English-style breakfast (eggs, bacon, etc. etc). I just ate it this morning. Steers makes a good chocolate-dipped cone, reminiscent of the Southern US food chain Dairy Queen.

As for the burgers, not to be too critical, but, well, as a child I helped my father raise a cow actually named "Big Mac", and, though that does not give me any real authority, I must say, to be honest, that burgers here are a touch meat-loafy.

This is no surprise, and for three main reasons: (1) Hamburg, NY, where the hamburger is said to originate, is over 6,800 miles from Botswana; (2) the original Hamburg Sandwich dates back to 1885, when the Menches brothers of Hamburg, NY ran out of pork and, reluctant to butcher more hogs in the summer heat, decided to try/fry beef. This is ample time for recipe drift; (3) Even the Menches brothers found fried beef to be bland, and so added coffee and brown sugar. So, not even hamburger #1 was 100% beef.

Despite my efforts, I have uncovered no secret recipes related to the common spices/additives used in Wimpy and Steer. (Believe me, I have asked.) My guess is corn starch, Worchester sauce and perhaps some soy.

As for sauces, except during WWI when anti-German sentiment led to the US changing the name to salisbury steak (want freedom fries with that?), the hamburger has thrived worldwide, leading all other portable, meat-between-bread recipes. The meat sandwich has therefore been subject to toppings ranging from guacamole to chili to "Thousand Island Dressing" to BBQ sauce to queso, and that is in the 48 contiguous States alone. Hawaii and Alaska have tried pineapple and lox, respectively. The Germans, sauerkraut.

The African toppings, while high in volume, are derivations of the standards: relish-laced ketchup at Wimpy (probably better on a hot dog...but franks not on menu) and “Steer Sauce” at Steers (a type of sweet BBQ, though could use more hickory). When ordering, to avoid soggy disappointment, I recommend ordering sauce on the side…and dipping. Or, you can do breakfast at Wimpy's, drive three hours east to McDonalds for lunch (indistinguishable from stateside version), then head back for a Steers dipped cone, the perfect afternoon snack.

Search terms - A cultural encounter, Part 4 (of 4)

2009-06-13T06:18:00.000-07:00

Continued from Parts 1-3 below.

The singing of “Kumbayah” continued.

The choir comprised a hundred sundry Baylor doctors, nurses, social workers, receptionists, translators, parents, grandparents, aunts, uncles and children. Represented countries, in addition to Botswana, included Kenya, Uganda, Zimbabwe, and South Africa. Oh, and Texas.
“Someone’s singing Lord, Kumbayah.”

I thought briefly of my sister and her husband in New Orleans, where Cajun, French-soaked accents once melted the words “come by here” together. Sarah and Alan, previously in the Peace Corps in Nicaragua, are now in medical school. They are going into global health, and they are going to have a baby soon. What a lucky child that will be. All of the bedtime stories and apples she wants.

I thought of my brother Nick, a musician touring from his hub in NY, NY, where he volunteers for Musicians on Call , a non-profit that sends performers to the bedsides of the sick and dying. I wondered if they ever sing Kumbayah. That is probably the song I would choose to hear.

Looking at the children in the clinic lobby as they looked back at me, I thought about other songs that I used to sing as a child. One started with the words “I’ve got the peace that passes understanding down in my heart to stay.” I never understood the song and always thought that we were singing about Tuesday, and wondered why the other six days were different. As I was growing up, my mother, a pediatrician, used to have Tuesdays off from the hospital, so I thought maybe that was it.

Today, at almost 34 years old, I do not know who that songwriter was who stated that he's/she's got 24-7 transcendental peace, but I can say with confidence that I am not quite there, not on Tuesday, Wednesday, or any other day. Not even most Sundays. I am, like many, virtually peace-free most of any given week's seven days, craving respite while at the same time reveling in the clarity and motivation provided by peacelessness.

As the last verse of “Kumbayah” was underway, I thought of another song from my childhood, one that I liked a lot, one that I had not sung in many years. Then suddenly it was my turn to speak. I said hello and asked if I could sing that song. The answer was an enthusiastic yes. (This is no wonder: A solo from a pallid foreign guy wearing a white collar shirt and tie is guaranteed entertainment.)

I began with the words, “This is the day,” my mediocre singing voice bouncing off the windows and concrete walls of the clinic lobby. Many of our 85 clinic staff attend the morning prayer, and were standing behind me. A few of them, recognizing the song, repeated the lyrics “[This is the day]” This made me very happy, and I continued.

“…That the Lord has made.” [That the Lord has made]

“Let us rejoice.” [Let us rejoice]

“And be glad in it.” [And be glad in it.]

And then, as the song indicates, I repeated the verses.

Then there was quiet. The audience, satisfied by the spectacle, clapped for us.

And so for a few minutes in the packed lobby of an HIV clinic in Botswana, someone was singing. While I do not know if God came by as we had requested that morning, I can say this:

In our impoverished, unjust, sick, hurtful, love-hungry world, sun, rain, and family are not always provided in the proportions we’d like. Health, food, friendship, even love sometimes disappoints. The peace that is said to pass understanding, that peace that we crave, often passes us by for reasons we don’t understand. No matter how many books, chapters, and verses we read, no matter how many songs we sing, peace is a hard thing to chase down.

Yet, no matter how garbled or offtune our words, and no matter how seemingly senseless our lyrics, the songs matter, and we must sing them. We must sing them with others. We must sing them to others, especially in their darkest hour. When alone in life’s throes, we must sing them to ourselves. We must work like heck to ensure that the chorus remains healthy and able to sing along. We should see that our children live long enough to learn the words and join in.

To me, it seems likely that one of the reasons that God goes through the trouble of making more days is to give us an opportunity to do this.

Fortunately, it is also a lot of fun.

* While writing about the song with the lyrics “the peace that passes understanding,” I read that the words come from the biblical verse Philipians 4:7. The book reportedly took its name from Philip, the famous king of Macedon(ia). My last name Phelps is derived from Philip, which is neither here nor there except that I had always been told that this was an English name derived from the Greek name Philippos which means "friend of horses" (philos="friend"; hippos="horse”). Now, despite being Texan, I have feared riding since my sister’s horse "Fido" tried to rub me off on a tree out by the Phelps barn in the early 90s. I am therefore relieved that there is a non-secular, regal genealogy that I can claim as an alternative. Given that everyone here in Africa, upon meeting me, immediately asks me if I am swimmer Michael Phelps' brother, and given that I almost always indulge them and say yes, I suppose that it does not much matter.

Search terms - A cultural encounter, Part 3 (of 4)

2009-05-01T06:45:00.000-07:00

Continued from Part 1 and Part 2, below

I arrived at the Baylor Clinic at 7:00am. I had been asked to give a brief speech to the children and caregivers that day but, despite the best efforts of Google and tedious introspection, I still had nothing to say. (Morning prayer typically runs from 7:15 until 7:30am, when patient registration and triage begins.)

By the time I arrived, the chairs were full with adults and children carpeted the floor, as usual. I walked through the matrix of faces, faces belonging to people born faraway from my birth-place. Faces of people who have never heard of white-tail deer, the Alamo, or the two-step. Faces with Tex-mex naïve palates. Faces with eyes following me as I walk by, as if I were a slow-moving tennis ball. (Had these eyes ever seen tennis? Of course, I reassured myself. Surely at least some had.)

Even as I stepped over kids and brushed against the shoulders of those with aisle seats along the narrow passage towards the reception desk, I felt very far away. That aching, uncomfortable, alienating feeling that couples speechlessness reminded me of a few bad first dates and those times I unwittingly sat at the wrong table in the high school lunchroom.

The sing-along started that morning as it always does, the Setswana words indecipherable and the harmony seemingly effortless. At about 7:20, the group transitioned into “Kumbayah”, a song that my parents used to sing to me almost nightly when I was young. The song title, as I understand, is a Creole blurring of the words “come by here”. The verses (“someone is singing, praying, laughing, etc”) are otherwise in standard English, so I was able to join in the chorus.

As I sang, I thought of all those nights when my dad and I would lie down and informally serenade God, asking him to drop on by. I remembered the bedtime stories that my father would tell me. They usually starred a protagonist named Freddy. He was a fish and, though my dad is an avid fisherman, this fish was benevolent and clever, unlike the sinister, tasty striped bass that we pulled out of the nearby lake Texoma and, once breaded and fried, ate with hushpuppies.

“Freddy the Fishy” was also verbal and, now that I think of it, amphibious. At the time, I did not know or care about gills vs. lungs. I knew nothing about Africa except that it was far and that people were once stolen from there.

Still singing, I thought of the other songs that I used to know. There was a pre-dinner song that a littler version of me used to perform when it was my turn to say grace. It went like this: “The Lord is good to me, and so I thank the Lord, for giving me the things I need, the sun and the rain and the family.”

I am pretty sure that the real words were “…and the apple seed” but I always preferred “family” because I didn’t understand the original lyrics. You see, we never needed to grow our own food and I simply threw the bitter, seeded core of my apples in the trash. An apple, I now know, used to be a perfectly suitable gift between friends and family. (No, not an Apple iPhone, but the actual fruit.)

Sun, rain, and family. I must have sung those words three hundred times. Now, I live on a sub-continent where subsistance farming is the norm, and work in a country that sits on a desert. I look around and see a troubled family structure being further wrecked by a hellion of a virus. As for “the sun, the rain, and the family,” only one of the three thrives here. The scorched earth sustains little, and that which grows is scrubby and thorny, for all that is not dense and sharp is eaten by the few, hungry animals that roam about. Apple trees do not grow under this sun. Apples are imported, and most kids will choose one over a hand full of candy any day.

To be continued...

HIV News Digest - April, 2009

2009-04-27T23:52:00.000-07:00

The following is a selected list of several notable HIV-related articles and news stories for April.

(1) Sooner is better: A New England Journal of Medicine article suggests we should start ARVs sooner. In the authors own words, "[there is strong] evidence that patients would live longer if antiretroviral treatment was begun when their CD4+ count was above 500." (Sax/Baden, New England Journal of Medicine, 4/30).

(2) We can do better: An accompanying editorial notes that, "[While] the battle to start providing antiretroviral therapy in the developing world has been won, the battle to provide the best care we can is just beginning" (Ford et al., New England Journal of Medicine, 4/30). Most African treatment programs start ARVs at a CD4 of 200 or, at best, 350.

(3) HIV no better (or worse) than diabetes? According to a study in South Africa, the Ivory Coast, Zimbabwe, and Malawi, for adult patients who start ART with a high CD4 lymphocyte count and no signs of advanced HIV disease, mortality is similar to that associated with diabetes. (Brinkhof MWG, et al. E, Mathers C, et al. (2009) PLoS Med 6(4))

(4) Is transmitting HIV worse (or as bad) as killing? The Ugandan Government is considering criminalizing HIV transmission a move that is believed by many advocates of prevention efforts to invokes stigma, discrimination and a disincentive for voluntary testing, and access to care and treatment."

(5) Does it not follow that HIV prevention is good? An Iranian appeals court recently upheld the sentence for two Iranian physicians brothers who implemented Iran's first HIV/AIDS prevention program. Arash and Kamiar Alaei received prison sentences of six and three years, respectively, The charge was plotting to overthrow the Iranian government.

(6) Before hitting the sack: An analysis of three recent studies (South Africa, Uganda and Kenya) found that heterosexual African men reduced their risk of HIV infection by half after undergoing circumcision. From an evolutionary perspective, one author said, “There are no more competitive advantages to keeping your penis in a sack.” (The Cochrane Library)

(7) China’s No.1: China announced in February that HIV/AIDS was the country's No. 1 deadly infectious disease in 2008 (UNAIDS)

(8) USA’s number is up: One person in the U.S. contracts HIV every nine-and-a-half minutes, and new infection rates are climbing among many groups. This and other messages will be dissiminated during a five-year, $45 million campaign to increase HIV/AIDS awareness in the States, where for many at-risk the epidemic has fallen off the radar screen.

(9) 1,200,000: HIV/AIDS-related mortality and prevalence among residents of 12 PEPFAR-funded countries (Botswana, Cote d'Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia), when compared with residents of 29 other sub-Saharan African countries that did not receive PEPFAR funds, was lower, with estimated lives saved in the seven-digit range, or around 1.2 million.

Search terms - A cultural encounter, Part 2 (of 4)

2009-04-19T08:40:00.000-07:00

This is Part 2, continued from previous posting. (See below.)

...The search terms “Africa” and “Bible” had several billion hits.

I first browsed a site on “The Africans Who Wrote The Bible”, where the author of the so-titled book passionately explained that black ancient Egyptians were primarily responsible for the book. A bible history site pointed out that only part of Africa—again, Egypt—was known by the Hebrews, and perhaps those countries now known as Libya. Next, in “Reading the Bible from an African Perspective”, the author explained matter-of-factly that “a literal reading of the Bible is the most acceptable reading in churches in Africa.” I imagined a few word substitutions: “A [monolithic] reading of the [African sub-continent] is the most acceptable reading in [libraries] in [the West],” and this made me grin.

But, it was time to get serious. I tried again, typing “Botswana and religion.” Wikipedia popped up and taught me that an estimated 70 percent of Batswana identify themselves as Christians, with Anglicans, Methodists, and the United Congregational Church of Southern Africa making up the majority of these. About 5,000 of Botswana’s 1.7 million inhabitants are Muslim, primarily from South Asia. (I drive by a large mosque every day on the way into clinic. In front, a sign reads “Islam Welcomes You.” Botswana’s CDC office neighbors an impressive minaret and dome.) Botswana is also home to ~3,000 Hindus and ~700 Bahá'ís. Six percent of citizens are practitioners of an indigenous religion called Badimo, and approximately 20 percent of citizens espouse no religion.

I found this breakdown of affiliations interesting, but it worsened my confusion.

No matter where one lives, the rules of cultural engagement guide almost everything. Failure to learn and obey them risks much (relationships, professional effectiveness, etc). But, no matter where we live, sometimes the rules are hard to predict, especially if religion is involved. For example, during a staff meeting in Swaziland, the meeting chair once insisted that the opening prayer be repeated after a colleague of mine, a US pediatrician, read a beautiful Buddhist prayer (the Metta Karuna Prayer, I believe).

Talking about God in any context is of course complicated. In university, I briefly considered 'the ministry' as a profession, but in the end, preferred clinical science, a vocation with tangibility and rules/methods that enjoy near universal acceptance. Simply put, at the time, science seemed safer. Now I can say with confidence: Still does.

I half-heartedly googled “safe bible versus”. This was not helpful. So, having no other choice, I decided to use common sense.

This concludes Part 2. To be continued...

Search terms - A cultural encounter, Part 1 (of 4)

2009-03-14T08:27:00.000-07:00

Bible translation status (red means that Bible is not in local language); http://worldmap.org

After a restless night, I spoke today at the Baylor Clinic’s morning prayer. Given how much I speak in front of groups as part of my current job, during such events my pulse rarely quickens. Earlie this week, when I was asked to stand in front of a full waiting room of children and caregivers and share a spiritual anecdote or teaching, however, the biochemical rush that couples fear immediately engulfed me, much like a fog. My cheeks warmed, my vision sharpened, and there was a soft but high-pitched buzzing in my ears.

I am no stranger to anxiety, but did not expect to feel it as a result of being invited to speak for five minutes to a group of our patients, especially when I had two days to prepare. I actually quite enjoy talking to groups of people, and I have become able to speak for about any length of time when the topic is pediatric HIV. I can speak about how the HIV virus looks, acts, and kills, how it evades capture and perplexes scientists. I can talk about the effects of the virus (physical, economic, social, cultural, political) and how Baylor’s Botswana-based programs are responding to this virus (clinically, programmatically, etc). I can explain why I believe that our response to the pandemic will define our generation…for better or worse. I can talk about how I feel when I watch an HIV-infected child die a preventable death, and how I feel when watching a child near death not only live but thrive.

But, when it comes to sharing my personal thoughts on spirituality with my African counterparts, words do not come as easily.

The two primary reasons for this are obvious: I am a Caucasian physician from rural Texas and, though a Methodist and dedicated to the golden rule and several others, I do not claim (or necessarily aspire) to have spiritual insight, per se.

So, I decided to look for some. For millennia, when seeking such insight, soul-searchers have reflected while peering into the night’s sky or perhaps sitting quietly in a peaceful place, legs crossed. I did not do this. I leaned over my desk and opened http://www.google.co.bw/.

My first search terms were: “Africa” and “Bible”

To be continued...

Selected quote #3: “Do not use free condom dispenser as waste bin."

2009-03-10T05:46:00.000-07:00

This was written on a sign affixed to the door of the men’s room on the second floor of the Botswana Ministry of Health.

This quote, besides striking me as a little bit funny, suggests two things: (1) Free things tend to be devalued, and (2) Whether containing condoms or cans of soda, dispenser design matters.

Selected quote #2: "Ungh, Ungh, Ungh … Ungh, Ungh, Ungh"

2009-02-27T05:43:00.000-08:00

Syncopation is the accentuation of a musical beat that normally would be weak according to a song's rhythmic division. Though difficult to spell phonetically, this quote was the highlight of my morning today. It came from the throat/mouth of one of the clinic’s Setswana-English interpreters, and each syncopated syllable corresponded to the the off-beats of the morning song. I call the song “Botswanana”, because that is the word in the song that most resembles a word that I have heard before. We sing it at a few times a week just before clinic starts.

As we sang and kept time, a 2 year-old child stood in the waiting area slapping his hands together. He was off beat and looked as if he were carelessly slapping at darting mosquitoes…but he was the reason we were all there.

Selected quote #1: “I never made a C.”

2009-02-20T05:40:00.000-08:00

These words were spoken by one of my school-aged patients. He has never made a C. He held his biceps up in the flexed position while saying this, for there is little so-called grade inflation here, and As and Bs are considered high marks.

Botswana destinations #3 & #4 – The Botswana flag and big, cloudless sky

2009-01-18T07:11:00.000-08:00

The Botswana flag against its most common backdrop--a cloudless sky.
(farm1.static.flickr.com)

Like my home state of Texas, Botswana has big skies. Like the dusty West Texas skies of George W Bush fame, Botswana's skies rarely bring rain. A few months a year, known as the rainy season, it rains some and sometimes hard, but not enough to neglect watering the yard...unless you wish it to return to a dusty desertous patch of land where grass once grew. (This is how I found mine upon moving into my apartment). The rainy season corresponds roughly with summer, though seasonal references mean little here--leaves and snow do not fall in Botswana, and spring loses it's romance when it marks the departure and not the arrival of the things green and alive.

As I discuss in my first entry on this blog (called "Cloudseeding"), rain and it's absence define life in this dry country. The land is flat, the desert plant life small, and the buildings few, meaning that the horizon can sink no lower and the sky that pushes down upon its edges does not have to push too hard.

Unlike many African countries where I have been, here the national flag is often flown. It is my impression (having been here now only 10 months) that this reflects the nation' patriotism, and indeed the inhabitants of this land, while facing many challenges (HIV being one), have much to be proud of.

The blue on Botswana's flag represents water. The motto on the national Coat of Arms is "PULA", meaning "rain". The white-black-white bands on the flag represent the goal of racial harmony among Botswana's people, as well as the pluralist nature of the society here. They are inspired by the coat of the zebra, the national animal.

Botswana Coat of Arms (images.vector-images.com)

Botswana destinations #2 – The perimeter of the Gaborone dam

2009-01-18T06:51:00.000-08:00

The Gaborone Dam. (www.picasaweb.google.com)

The Gaborone Dam is the water source for Gaborone. Because Botswana is very dry, the dam’s construction a century or so ago necessarily preceded the growth of Botswana’s capital city.
The dam is home to the “Gaborone Yacht Club” and the “Kalahari Fishing Club”, but this entry is about neither, nor is it about the dam itself. Here, I will share with you the highlights of the approximately 21 mile trail around the dam, which I recently biked.

Leaving from a friend’s home near the Ladies No. 1 Opera House, we set out at about half past seven and, as a few miles required walking and carrying one’s cycle, returned about three hours later.

Highlights of the trip, if I may describe a few, can be grouped into three categories: plant life, animal life and industrial landmarks.

As for plants, let me first say two things about the thorn bushes of the Botswana bush: they are ubiquitous and they draw blood. Bike tires must be tubeless and specially slimed to “Self-heal” when punctured, which occurs every few meters. Besides thorns, the “resurrection plant” warrants mention, for it turns brown in the arid winter, greens near rock puddles in the rainy season (~December-February), and smells of a Swedish sauna (an odor fusion of cedar, sweat, ozone, and eucalyptis).

The resurrection plant. (http://www.info.gov.za/ )

Moving to animals, one of the seven-person cycling delegation told me of a fresh-water shrimp that also inhabits these puddles, impressive given that this extreme habitat remains dry most months out of the year. They are called, and I am not kidding, the African Fairy Shrimp (Branchipodopsis wolfi). Alas, I was unable to spot one of the crustaceans during the ride, but I did find an article on fairy shrimp egg dispersal, published by the scientist that taught my co-cyclist of their existence. In addition to the shrimp, we spotted several other animals (humdrum in comparison, of course), including impalas, black-backed jackels, warthogs and dragonflies.

A black-backed jackel (www.farandawayphotographicarts.com)

Landmarks (our final category) included a piggery, where, according to my co-rider, “intensive pig farming” takes place, and a brick kiln (where nearby clay deposits are mixed with ~10% charcoal and baked around a central fire). The brickmaker was drying fresh fish from the dam on the top of the structure.

Botswana brick kiln near dam. (www.picasaweb.google.com)

The final landmark of note was the guard station where our trip began and almost ended. A young, rule-abiding uniformed guard demanded to see our permits that permitted us to ride our bicycles around the dam. After our party pointed out no fewer than five holes in the perimeter fence and as many trespassing, permit-less fishermen and cattle herders, the permit requirement was waived.

And thank goodness, for it was a nice loop, and the clouds mercifully blunted the mid-summer desert sun.

Less small- A patient encounter

2009-01-11T05:08:00.000-08:00

www.blogs.targetx.com

Human beings almost never spontaneously hold a strangers hand, but, for Mathambo, it was natural. As I walked in front of him to the exam room, he took my hand in his, and, when I looked back, he smiled up at me.

As he did this, two other young children were walking toward us from down the hall. For a couple of seconds, it seemed as if Mathambo was going to clothesline the children, or at least make them physicially break his grasp (as we used to do while playing "red rover" in the school yard). Though I did not know Mathambo well, this did not seem in character. Sure enough, at the last minute, he raised his hand (with mine) and allowed them to pass.

“See. I am big!” he told me as he let our hands fall again. Mathambo, four and a half years old, was 15kg heavy and 95cm tall. This is big for a two and a half year-old, not a child nearly twice that. But, he was bigger than the oncoming pediatric traffic, and certainly bigger than he was a year prior, when he reached the median age at which untreated, vertically-infected children used to die before having access to ARVs. In any case, I was not about to refute him.

Once in the exam room, I looked over Mathambo’s chart and the boy himself, noting that he was doing well (undetectable virus, high CD4 count, no clinical evidence of disease, and still smiling). I told him and his mother this, and Mathambo began dancing.

I told him that his medication adherence was 100%, and he began dancing with even more vigor, shouting “I am big. I am big!” His choreography was reminiscent of the “grapevine", with sidesteps, stomps, and the occasional clap.

One of the red rover children that had been walking the clinic's halls must have heard the proclamations, for he opened the door. Younger, littler, and sicker than Mathambo, the child had thin limbs, visible ribs, and a melon-shaped tummy. His face had the aged appearance that remains when so-called baby fat is not there shape a baby’s face, leaving young skin hanging on young bones, baggy, protruding eyes, and loose jowls. The loose-jowled child giggled and bobbed his knees a few times in sync with Mathumbo’s beat.

“Big!” Mathambo reiterated.

Mathumbo’s emulating counterpart gave me a quick glance, giggled some more, and, with some effort, closed the wooden door.

Botswana photo series - #1: "Traditional dress day"

2008-12-06T22:35:00.000-08:00

Several Baylor clinic staff in traditional Botswana dress

My ever-generous parents recently bought me one of those "Canon Rebel" series digital cameras. I am not typically 'rebellious', nor am I a particularly good photographer, but, in an effort to counterbalance the bland internet stock photos that I often post, I am going to use the device as an excuse to begin attaching photos of note on this site. The above photo, while taked before my recent acquisition, depicts several of my colleagues at the Baylor Centre where I work.

Listening through both ends of the stethoscope - A patient encounter, Part 2

2008-12-06T22:18:00.000-08:00

Continued from previous entry...

The first patient that listened to my chest did not seem to hear a thing, not surprising given how loudly he was laughing. While I went on to switch sides of the stethoscope and listen to the child’s heart, I hardly needed to. A child who is taking ARVs consistently and laughing is rarely in danger of being ill, making laughter an excellent screening tool.

The next child did hear my heart, and was able to clap in unison with it. After taking the stethoscope off, her little brother took it from me and held it up to his ear like a telephone. “Hello?” he said.

The third patient, while listening to my chest, told her father, who was asking me a question, to “please...not talk” as she was “not finished with the heart listening yet”.

The fourth child, after examining my heart, insisted on listening to his mother’s, his grandmother’s, and then his own. He suggested that we go out to the waiting room to continue examining everybody, but I talked him out of it. “They have to wait their turn, just like you did.”

The next child, when I placed the listening end into her ears, just cried. It turned out that she had a painful ear infection. This was also news to mom, leaving me feeling a little less guilty.

If any of the patients are to become health care providers, the next one is a leading candidate. She asked me to hold my breath while she listened to my heart. After a very long thirty seconds, she said, “breathe now.” She then asked me to turn around so that she might listen to my lungs, which she did while asking me to “breathe deep like blowing out a candle”. (I often use this trick to help kids understand what a deep breath is.) After this, she gave me a concerned look then asked me to please lie down on the exam table. I declined, instead writing in her chart, “HIV encephalopathy and developmental delay, previously of concern, seem to be resolving.”

I continued to see several more patients in this fashion, learning something about each one.

Then came my last patient of the day. Her name was Mary. (To be continued.)

Listening through both ends of the stethoscope - A patient encounter, Part 1

2008-11-07T23:00:00.000-08:00

www.merrimack.edu/

There are two ends to a stethoscope, and it matters which is which. At least I used to think so.

I once put on a stethoscope with the earpieces turned around (for these two-ended diagnostic tubes are also two-sided). I was a first-year medical student, and there was no reason for me to know better. Still, I recall vividly my feelings of embarrassment and awkward self-awareness after I had unwittingly demonstrated to the patient and mentoring physician in front of me that I had no idea what I was doing.

In well-meaning words with a slightly demeaning tone, the teaching physician explained to me that, because of the anatomy of the human ear, if the earpieces are in backwards, the doctor cannot hear. I believed him at the time, but now I know that he was wrong.

[As those who have read this blog before know, my patients are HIV positive children. Due to the humanity and diligence of scientists and advocates, in recent years, these children have had access to life-saving medicines-so-called ARVs. By some miracle, it is my job to help them take these medicines, and take them appropriately. The result is that, once on ARVs for several months, they are rarely sick. They have HIV but are on the correct and merciful zone of the healty child-to-AIDS spectrum. In other words, when I listen to the hearts and lungs of these children, they are essentially all normal.]

As a pediatrician, I was taught by many men and women in white coats to place the forked end in my ears and to place the end with the bell and circular disk on the patient. Then, yesterday, I began use the patient's end of the stethoscope, and I gave the patient my end. In other words, I asked the kids to listen to my chest.

In doing so, I learned that I can listen...and hear...through both ends of the stethoscope.

To be continued…

One hundred and one Botswana destinations: #1 Soweto

2008-11-04T20:00:00.000-08:00

Km 26 (or ~mile 15), photo courtesy of Dr Andres Gomila.

In my previous blog, written from Swaziland (http://www.pediatrician-in-swaziland.blogspot.com/), I listed a couple dozen local destinations that were worth checking out. Here is the first in a series of destinations that can be reached from Botswana.

Soweto (Johannesburg, South Africa's SOuthWEst TOwnship) is actually equidistant from the border of Swaziland and Botswana, about a five hour drive from Gaborone. Last weekend, with a group of friends, I ran the Soweto marathon. For those who have not run 26mi and three hundred and something yards, I can now tell you that it hurts.

I wrote my name on my shirt so that the people of Soweto might cheer me on...and they did. Though pronounciation varied from "Ree-on" to "Ree-yon" to "Rye-ann" "Hy-ahan" to "mlungu" (the last one simply means "white person"), 30 seconds did not pass without my hearing my name. I received no less than five hundred such cheers, maybe more.

Soweto is an historic place. It is home to an estimated 65% of Joburg's residents. Over past decades, Soweto's citizens were pulled there by the need for cheap gold mine labor and pushed by forced removals from legally-designated white areas.

Civil rights were fought for an won here. The June 16, 1976 Soweto Uprising led to the deaths of 566 people and, in their aftermath, economic and cultural sanctions were imposed on the nation (and its the apartheid government) from abroad, while Soweto and other townships became the stage for violent state repression. Since 1991 this date and the schoolchildren that were killed have been commemorated by the International Day of the African Child.

It is humbing to run a marathon, for at some point strength whithers, pain dominates your consciousness, and your legs, well, they just stop working. More humbling still is that, when it comes down to it, I know little of strengh and pain compared to those who call Soweto home. Nonetheless, they watched me slowly pass and shouted "Goooo Ree-yawn!" "Good work Mlungu." "Do not give up!" "Go! You are almost there!"

On one particularly difficult hill late in the race (around mile 22), an older gentleman came from behind me (for I was being passed by many at that stage) and took my hand. He clasped it with alternating, interlocking fingers. "We are going to do this together." he said. "We are going to run up this hill."

And we did.

--

[I have several other images from Soweto that I will share once I find my camera, which is arond here some place. Stay tuned.]

Good girl - A patient encounter

2008-10-06T10:00:00.000-07:00

Pona, eight years old, slowly and ceremoniously took a piece of paper out of a plastic sheet and handed it to me. She placed it in my hands with such care that I myself began to fear that I might drop it. I worried what might happen if I did. Might it shatter?

Once I had a secure hold on the leaf of paper, I saw that it was a page from a hand-drawn calendar. Written on the top of the page in perfect block lettering was a name--“PONA”--and the previous month: “SEPTEMBER 2008.”

Below this text were perfectly square, ruler-guided boxes representing each day of the month. Within each of these boxes were two small smiley faces. Each sticker, it seemed, represented three pills that the child had swallowed on that particular day.

“Wow…This says that you took all of your medicines!” I said with appropriate fanfare.

“She is a good girl,” said the grandmother, seated beside Pona in one of the exam room’s small wooden and fabric chairs. Hearing this, Pona stood a bit taller.

It was then that I noticed the grandmother’s shirt, which read, “Live and let live. End stigma and discrimination.” On her handbag were the words: “We demand free and compulsory education in Botswana,” and “We recognize and respect women’s rights.”

“I like the messages on your shirt and bag,” I said.

“Why doesn’t your tie say anything?” she asked.

I did not know how to answer. “What should it say?” I asked, glancing down at the faux-silk maroon kerchief dangling below my chin.

“Anything you want it to say,” she replied.

I thought for a few seconds and came up with no inspiration messages, so I turned to Pona and asked her what my shirt should say.

With a smiling face, she said, “Pona took all of her pills and she is smart and not sick...and...”

"And?"

"...and good!"

"A perfect message for my tie!" I proclaimed. I will have to drop off the tie for printing later.

Pona stuck a small smiley face midway between the tie's knot and inverted triangle, so that I would not forget.

Team captain - A patient encounter

2008-09-23T10:48:00.000-07:00

The time had come for me to quiz the child in front of me. His name was Letsego. The quiz is part of a step-wise process we call "disclosure", where a child is made aware of the essential components of his illness and treatment. He seemed to know these questions were coming, and paid careful attention.

MD: What are the names of your medicines?
Child: AZT, 3TC,and… N…VP!
MD: Awesome. Why do you take them?
Child: To have strong soldier cells.
MD: Great! What do the soldiers do?
Child: They fight the bad guys.
MD: Perfect. Who are the bad guys?
Child: The HIV viruses.
MD: Good! How clever you are. Do you have any questions for the doctor?
Child: When will I be strong so that I can play football?

The child paid even more attention. An electricity-like sensation, originating in my chest, spread to my arms and legs, briefly occupied my hands and feet, then dissipated. It was, as I have come to understand it, the physical manifestation of compassion made heavy by anxiety, the feeling I get when I want to do something good but worry that I might falter.

Letsego was a 8 year-old boy, and he wanted to play football (“soccer” for those of you who associate football with helmets and hands). The boy had answered my questions, told me things to show me that he knew what I wanted him to know, to demonstrate that he could parrot the trivial details that we doctors and other adults fixate on: names mostly.

Now it was his turn, and he wanted to play with his friends, so he asked me when he could. His eyes, which had witnessed the death of two parents, the withering and near death of his baby brother, both pointed at me. His hands, hands that usually held a cattle prod in dusty pastures instead of a pencil, rested palm down on his knees. His back, which spent nights pressed against a hut floor, was straight. He tilted toward me. His expression and posture were that of a child sitting impatiently on a bench while teams are being chosen before an informal schoolyard game, waiting for his name to be called while thinking “pick me…please pick me”.

MD: So, you like football?
Kid: Yes.
MD: Why?
Kid: Because it is fun.
MD: It is isn't it. Hmmm. Let's see. I have an idea. Every visit, you come in and show me that you have been taking all of your medicines, okay?
Kid: Ok.
MD: Then, to make sure the medicines are working, you can tell me how football practice is going, okay? But, start by kicking the ball around with friends, and practicing shooting into the goal. Only run if you feel strong and if you can breathe well.
Kid: Ok.
MD: Do not make yourself too tired, but keep practicing because I can see that you are already getting stronger from the medicines. Sound good?
Kid: Yes [smiling]

Letsogo stood. His small, diminished body reminded me of the physique of those kids who used to get picked last, those that were placed in the least important defensive positions, like left field in baseball or, in soccer, left fullback.

But, everything about the boy (except for the body itself) dripped with confidence.

Fortunately, bodies, when permitted, heal, especially young ones. Once healed, they run and kick as well as the next. Some better even, for having wanted to so badly.

Spirits lifted - A non-clinical patient encounter

2008-08-10T02:01:00.000-07:00

To meet local requirements for the disabled, the Baylor Centre where I work has an elevator. [As an aside, individuals with disabilities here are called “paraplegics” and elevators are called “lifts”. Both substitutes seem incomplete as there are many disabilities that are not paraplegia and elevators do not only lift. Nor do they only elevate, I suppose….come to think of it, “disabled” as an adjective leaves something to be desired. So much for my defense of American argot.]

So, as I was saying (or trying to say before I backslid into above amateur linguistic interlude), our clinic has an elevator. It is a simple elevator, not like those in Houston’s Texas Children’s Hospital where there are stipples of light reminiscent of the night sky above and wavy mirrors like those in a two-ticket circus house. However, as there are few multi-story buildings, the device is a bit of a novelty around here, and few of our patients have seen or used an elevator. An ascent/descent on the automated lift is so highly sought after by some of our adolescent patients, in fact, that we have put into place official restrictions on its use solely for recreation. The more assertive teens still try to finagle a ride, for that is what adolescents do. Regardless of continent of residence, teenagers finagle.

Younger children in the waiting room (pre-finaglers), with expressions of wonder and nervous anticipation, watch the closed frosted silver doors with the anticipation of a child about to open a gift, or watch a firework display. When it opens, the response is almost universally one of gleeful rejoice, as if a wonderful thing has happened.

The wait to see a doctor in the Baylor Centre is sometimes quite long. Though I prefer the stairs, I sometimes take the lift down to see if I surprise any spectators below. It feels sort of like jumping out of a music-less, adult-sized jack-in-the-box.

I have never jumped out of a cake, but it feels something like that, I imagine. Cleaner, though.

“If you can’t say anything un-nice…”, Disney World, and other illusory constructs - A cultural encounter

2008-07-13T06:32:00.000-07:00

www.content.answers.com

Dreadful things happen in Africa. Even those that have never been to the continent can name three or more dreadful African things.

I can name plenty.

I can also name several dreadful things about Disney World’s Magic Kingdom (queues; gum on the sidewalk; castle actually uninhabited; that vague creosote odor; teenager dressed as Mickey hard as heck to find; “it’s a small world” lily-white and pretentious; central Florida is all around you; etc). I can certainly divulge plenty of horrible things about each the solar system’s inhospitable eight or so other planets (Jupiter, for example: stormy; cold; gaseous; excessive moons; crushing gravity; that silly, mysterious “Great Red Spot”; no Wal-mart, etc.)

As this blog implies, I live in Africa and, despite getting no kickback from the, AU, SADC, or local Chamber of Commerce, I maintain that there are several not-so-terrible things here.

As an example, I have included the story below. Like most stories in this blog and the Swaziland version that preceded it, it showcases one of the continent’s many protagonists.

For no reason in particular…except to generate intrigue, I will call this brief story “Deus ex machina.”

In my free time, I like to mountain bike. Recently, we took a dusty, grueling loop in Botswana’s so-called “bush” (of Ladies No 1 Detective Agency fame). At our destination—the parking lot of a BP garage—one of the group, to his dismay, noticed that his GPS, which he had secured to his handlebars that morning, was affixed no more. Retracing our steps (or rather tire tracks) some 10km's back proved fruitless.

Two weeks later, about half way into a similar bush-ride, we encountered a lady standing on the single dirt track deep within the rural countryside. In her hand she held the GPS device. She had found “the telephone that didn't ring" in the grass near the trail two weeks prior and had been waiting since early that morning for “the men on the bicycles" to pass by. She had stood in the same spot all day the week before, but we had not ridden that weekend.

Neo was her name. Thanks, Neo.

Quand on a terminé sa toilette du matin, il faut faire soigneusement la toilette de la planète – Eight patient encounters.

2008-07-07T12:20:00.000-07:00

www.new-year.in

1) She was six. She came in the room and gave me two thumbs up.
2) He was seven. He was given stickers for remembering the names of his meds, one on each hand, and, to protect them, he spent the remainder of the consultation (fifteen minutes) with his hands held upright, as if holding an invisible basketball.
3) He was sixteen. He had no family, at least none that claimed him. He was by himself at the clinic. He was not attending school. He asked if we could help him become a student again.
4) He was five. He spent the visit playfully chewing the edges of a Styrofoam cup, until there were about a hundred such pieces scattered around the floor around him.
5) She was nine. She was angry with her mom for delaying her visit with the doctor. (Mom had been next door refilling her own ARVs.) I reached out my hand for a high five. She frowned at me. I asked what was wrong. She said she was hungry. I gave her a cookie. She smiled, gave me a high five, then remembered she was cross and frowned again. I gave her another cookie. Her mood was thereafter cured. The virus that brought us together was not, but it was not detectible in her blood.
6) She was eight. “My last name means ‘little snake’ she explained. “The snake lives underground and is not a poisonous one. We only see it when we plow. It is a nice snake.” This marked the very first time I had heard an African compliment a snake.
7) He was five and named Prince, but his name was pronounced “Prin-see,” with an emphasis on the second syllable. When asked how he was, he said “Well, doctor, I am just fine.” His mother, in agreement, said, “Prin-cee is very well.”
8) She was eight. She looked four, maybe five. She had a thin face, with sunken cheeks. I asked her to draw a flower for me. She had drawn the same flower a year prior and I wanted to see how she was developing. She refused. “I want to draw a boy,” she insisted. She drew a boy holding a flower.

Because of the HIV medicines now available to these eight and tens of thousands of other African children, they have the opportunity to survive childhood...just like we did.

Isn’t that just wonderful?

--

"For me, this is the loveliest and the saddest landscape in the world...I've drawn it one more time [below] to be sure you see it clearly. It's here that the little prince appeared on Earth, then disappeared. Look at this lanscape carefully to be sure of recognizing it, if you should travel to Africa someday, in the desert. And if you happen to pass by here, I beg you not to hurry past. Wait a little while, just under the star! Then if [a child comes to you], be kind! Don't let [him] go on being so sad: Send word immediately that he's come back..."
-The Little Prince, Antoine de Saint-Exupéry

Dr. Han plays the violin

2008-06-29T06:05:00.000-07:00

Dr. George Han

I sat down in the waiting room again this morning (see previous entry). It was the last day for one of the North American physicians named George Han, who had worked in Botswana for almost a year. To commemorate the occasion, and he had volunteered to come in and play his violin for the Baylor Clinic’s patients and staff.

It was only 7:20 but the clinic was bustling. Patient registration and triage was beginning, and nurses and physicians were darting from room to room escorting patients and retrieving charts. The youngest kids were scurrying about laughing and squealing, playing some simple and no doubt universal game that I long ago forgot how to play. Several older children and caregivers around me were looking over the medical records they had brought. I felt a bit bad for them, for we health care providers make the description of even the simplest sickness incomprehensible to the lay reader. (Jargon makes us sound and feel more expert, I suppose.)

One child was not playing or reading. He simply rested his elbow on his lap and his chin on his open palm, and looked at me inquisitively.

George had asked me to take pictures and video of his performance and so I stood up as he started to play. The crowd, hearing the music, went wild. Like me, they seemed to prefer the fast parts. I was near certain that the appreciation for fast violin ensured that the crowd would love bluegrass, and this left me with a feeling a kinship. As I slapped my thigh and tapped my toe to the beat, I did not feel at all too far from home.

Thank you for the music, George…and everything else you did for the children of Botswana. [George is joining the CDC’s Epidemic Intelligence Service in the upcoming weeks.]

The beginning of a day not without pretty things - A [well-lit] patient encounter

2008-06-23T10:01:00.000-07:00

Upon arriving to work, I enter through the waiting room, for there is no other way to enter. That is just as well, for walking through a labyrinth of knee, waist and chest-high children reminds me why I showed up to work in the first place.

Usually, I just wave to whoever is noticing my entrance as I walk through. There is usually a lot of commotion in the waiting room, and so few notice. I then stop at the reception desk and say good morning. Then, I walk upstairs to take care of administrative duties. Some days I come back down to see patients. Many days I do not.

Today, I arrived a little early and, to my surprise, there was singing. This was not surprising in and of itself, but rather because the singing was fifteen minutes earlier than the usual time, which is 7:30am.

I sat down to listen, wishing that I knew the words and what they meant. Well, in a sense I knew the meaning. The song meant that I was in Africa, where a day is started with a song…as are most meetings or other important gatherings. The song meant that I was not in the United States, where the day starts with, let’s see, coffee…and maybe some email. The song meant that, though many in the room had HIV and would wait in cramped quarters for much of the day to have their life-preserving medications refilled, the day would not be without pretty things.

I sat in the back row of the lined chairs of the waiting room, listening. To my left, a baby of about eighteen months was clapping. His performance was spotlighted by a patch of sunlight entering through the high windows of the clinic lobby. The beam of light, no more than eight inches squared, gave the child a peculiar but striking golden glow. When the music stopped, the illuminated baby said “aaah, aaah, aaah…” to the previous beat, stopped suddenly, looked around, and giggled.

He did not know the words either.

The symbolism of heroic wrestler John Cena – A patient encounter

2008-05-26T13:01:00.000-07:00

Granny shouted “Hurry up man!” as I was about to introduce myself. With these words, Simon darted from the room.

“He left his ARVs in the waiting room,” the grandmother explained after the child sprung off of the exam table and sprinted out the door. As she finished the next sentence (in Setswana but likely a reference to how children often forget things), the sound of frantic footsteps grew louder in the hallway until Simon reappeared panting, the medicines held in both hands. His arms were outstretched above his head.

Though it required a double take, I noticed that the pose was identical to that held by a fierce, built man depicted on Simon’s t-shirt. I asked about this man, and Simon explained that muscular man on the shirt was his hero, John Cena. Well, I did not know who John Cena was, but as I looked more closely at the shirt I noticed that the letters WWE were inscribed beneath the image, and, above the man’s head, clasped in both hands, was a large golden belt.

“Simon, who is this guy?”

“He is the WWE wrestling champion,” answered Simon.

Simon is not a sick boy. I mean, yes, he has HIV, but he is healthy. His speedy exam-room-to-lobby-back-to-exam room time alone reflects a level of fitness many only dream of. He does not embody the brawny, enhanced, made-for-TV fitness of Cena, mind you, but rather that of an athletic fifth grader.

After confirming that Simon was doing well and had taken 100% of his medicines (most of my patients meet both of these criteria), I asked him if I could take a look at him. Simon jumped up on the exam table, landing rump-first and loudly. As he thumped down, he said “Powerslam!” Then, with theatrical but seemingly sincere enthusiasm, he opened his mouth wide and tugged vigorously at his shirt to give me a view of his throat and listening access to his chest.

“Powerslam?” I asked.

“It is one of the moves that this wrestling man does,” the Grandmother said. “The kids are all crazy for this John Cena.”

Simon nodded passionately.

As I have discussed in previous posts, health care providers often use a soldier analogy to explain how the body fights off HIV. Medicines, we say, keep the body’s soldier cells (CD4 cells) strong. The soldiers, as long as they stay strong, make the HIV go to sleep. This symbolism works well in Botswana, where the uniformed Botswana Defense Force is almost universally popular among school-aged children, though the Force’s peacetime activities are largely themselves symbolic.

I asked Simon if his wrestling hero had a sleeper hold. He asked me if I was referring to the Sidestep Toehold Sleeper. I told him yes I was.

I told him that, because he liked wrestling so much, his soldiers probably knew that move, and that the medicines would help the soldier cells perfect it.

He loved that.

--

If I were to have asked Simon to fill me in on additional John Cena trivia, he would have told me, as Wikipedia did later that night, that Cena was himself in the Armed Forces, and sometime even wears a Marine uniform for his big, televised WWE entrances. If I would have asked Simon about other, non-sleeper moves, he would have told me about the Spin-out Powerbomb, the Jumping Release Fisherman Suplex, the Running Flying Shoulder Block, the Twisting Belly to Belly Side Slam, the Sitout Hip Toss, the Diving Leg Drop Bulldog, and, of course the Powerslam. Actually, to be more exact, the Fireman’s Carry Powerslam.

Imagine a CD4 with those antics in its repertoire.

If pushed for even more Cena trivia, Simon would have told me that, to fire up his countless fans, Cena often shouts the following trademark phrase: “You can’t see me!” after which he performs his theme song “The time is now.”

As a CD4 mascot, Simon’s hero is also mine.

Grace - A Patient Encounter

2008-05-20T13:12:00.000-07:00

“You promised me a book.” Grace said.

Grace had wire-rim spectacles and a contemplative facial expression, uncommon for her age.

I had not promised her a book, but I did not tell her this, for I was intrigued.

“What kind of book did I promise you?”

“I don’t know,” she said…”Maybe a novel.”

“What kind of novel?”

“Any,” she replied.

“Remind me when you are about to go to the pharmacy,” I told her. I would not need reminding, for I tend to remember the unusual. A pensive teenager who makes up a story to get her hands on a novel is unusual.

“So, how is school?”

“It is nice,” Grace replied.

“What do you study?”

“Everything,” she said, flashing me a glance as if to tell me that she knew that I knew that fourteen year-olds were always assigned a general curriculum.

Of course, I could not resist asking, so I did: “What do you want to do when you get older.”

“I want to be a doctor.”

“Would you like to work here?” I asked pointing to the floor of the consultation room.

“Oh, yes.”

Hearing this, her grandmother, who had begun caring for Grace when her mother died, suddenly said, “They always leave. They never come back. They go away to the UK or USA to study and they say that they are going to return, but they don’t.”

“But Grace will come back.” I said. “She is going to be the best doctor in Botswana someday.”

Grace smiled. “In Africa,” she said.

“What’s that?” I asked, not understanding.

“The best in Africa.”

I looked into her bright, sincere eyes. I shined a light in them, and watched her pupils get smaller. She squinted. I looked into her healthy mouth and ears. I listened to her strong heart and lungs. Her belly was soft but ticklish. She had no abnormal rashes or lymph nodes. Her hands were warm and pink with well-oxygenated blood.

I finished the exam, wrote her prescription for ARVs, and took her by her left, healthy hand and led her to our library, where there is a small collection of children’s books...and novels.

She narrowed her choices down to The Hobbit, Prince Caspian from The Chronicles of Narnia, and A Series of Unfortunate Events, Book One. She thought for a few seconds and then picked up the first of thirteen small volumes that tell of the adventures of three skilled siblings who find themselves in an endless string of predicaments.

“A good choice.” I told her. “Now, if you bring this one back, I will give you the second one to read, and then the third…and so on.”

“Thank you,” she said. I handed her a prescription. “Thank you,” she said again.

As she said this, I wondered as I do most days at how incredibly lucky I am. I get to show up to work and help restore the immune system of a child that the world came very close to giving up on, a child that was almost left to die. I get to encourage this nearly forgotten child to become Africa’s best doctor. And, I actually get paid to do this.

Then, this clever child who has waited several hours for a simple refill of HIV medicine thanks me for doing a job that makes me happier than anything else I can imagine.

I hope that Grace, with her discerning eyes, can see this.

John 11:35 – A patient encounter

2008-05-11T07:00:00.000-07:00

Last week, I told a mother that, because she received medicines to prevent transmission of HIV to her newborn son, he was born HIV negative.

She wept.

Mugabe, Zimbabwe, Children and HIV - Part 1 (of 10)

2008-05-11T06:40:00.000-07:00

Zim dollars now come in ten million dollar bills, worth approximately ten dollars. If you find yourself with one, spend it quickly, as it expires within months.

There is a lot of talk about Zimbabwe these days. Robert Mugabe was once seen as a refreshing thinker, an embodiment of the hope for a peaceful, integrated postcolonial democracy. His country was the breadbasket of southern Africa and by any account a developmental success story. Now, Mugabe is referred to by many as “Crazy Bob” and, by most all accounts, the country is inching toward the precipice of war.

Mugabe’s journey from hero to villain to pariah led his nation on a similar journey, and now a millionaire in Zimbabwean dollars is approximately a one-aire in US dollars. There is no "Dollar Store" in Zimbabwe, for it takes ten thousand Zim dollars to buy just one penny.

Botswana, where I currently live, is one of Zimbabwe’s neighbors. Zimbabwe is a common topic of conversation here and has been for decades (well before Mr. Mugabe became Crazy Bob). While cultural commentary on this new site will be no means be limited to the topic of Zimbabwe, this is the first of a series of entries focused on this nation in particular.

The reason for this is simple: I am not an economist or political scientist. I am a pediatrician. The media coverage of the inflation and the election are interesting, but one must not forget that HIV in Zimbabwe kills over 40% of the children that die before five years of age (see histogram below). Violence is a very effective killer, but HIV is better. When we tally the lives lost after Zimbabwe recovers, I assert that the number will depend more on the preservation and resilience of the country's public health infrastructure than it will on exchange rates, party politics, machete's or bullets.

Last week, I was in Zimbabwe visiting Victoria Falls, and, as I boarded a Zambezi riverboat, a group of Zimbabwean men in traditional attire were singing a song that, when translated, has as its chorus, “Hard times don’t kill.”

Alas, this is untrue.

The videophone and the popstar - A patient encounter

2008-05-08T11:29:00.000-07:00

For those of you who followed my Swaziland blog (www.pediatrician-in-swaziland@blogspot.com), you have probably read several of my “Patient encounter” entries. Below is my first such account from here in Botswana.

Mpho should have died five years ago, but today, when I met her, she was very undead.

As I opened the door to the exam room, I saw a crouching child. Her feet were at shoulder width and her knees bent. Her left arm was outstretched, her index finger pointing at a nearby cell phone, which a nurse was holding up as if taking a photo. The girl’s right arm was bent, held at a ninety degree angle as if she were flexing, but she was not flexing.

She was, as far as I could tell, dancing. Her right hand was flat and upright, fingers outstretched. Her forearm darted back and forth quickly, leaving the five outstretched fingers to flap and quiver like sailcloth on a windy day. Her knees bobbed slightly to the beat and her shoulders swayed at approximately quarter time.

There was no actual music playing. Rather, the girl was singing the song to which she danced, her rendition of a local pop tune.

A few seconds after I walked in to examine this new patient and refill her antiretrovirals, the performance stopped and the scene was suddenly that of a ordinary clinic room. Immediately, Mpho rushed over to the nurse’s side and stared at the phone.

The child smiled broadly as she watched the cell phone’s playback of her performance. She tapped her toe to the beat of her tinny, digitized vocals.

After I watched Mpho sing and dance, I looked through her medical chart. This girl had been so sick, seemingly destined to die in an era (a very recent era) when HIV medicines were largely unavailable. Her destiny was to join the countless others that died in childhood, having never received treatment for a treatable infection.

Well, thanks to the vision and determination of some good men and women, ARVs became available and Mpho did not die. I know this because I saw six-year-old Mpho today.

I know this because dead six-year-olds do not dance. Nor do they sing. Nor do they watch the screen of a cell phone with a wide, proud grin.

Two bar graphs

2008-05-06T10:51:00.002-07:00

To begin to frame the problem of pediatric HIV here in Botswana and the Baylor International Pediatric AIDS Initiative's response to date, I have attached two histograms. Comments to follow...

Deaths Under Five Years of Age Attributable to HIV/AIDS

Annual Pediatric HIV/AIDS Death Rate: Botswana Baylor Center of Excellence

Cloudseeding - My arrival to Botswana

2008-05-05T11:42:00.000-07:00

It started raining when I crossed the Tlokweng Border Gate into Botswana for the first time. I have since been told that this is auspicious.

Botswana, you see, is quite dry. It is no surprise that the currency is called the Pula, meaning “rain”. The Setswana word for rain can also be found within the names of the several of the tribes previous royal families: Pule, Moirapula, Mmapula, Rapula, Mpule, etc.

Rainmaking (morok’a-pula) and cloud seeding (go rokotsapula) are longstanding historical institutions in Botswana. According to the book “Setswana Culture and Tradition” (2006, Pentagon Publishers), rainmaking activities have historically included ancestor worship, the sacrifice of an unspotted black ox, wearing necklaces made of hydrophilic plants, and concocting “rain medicine” from a slaughtered antelope’s hair. The book also reports that it was considered prudent to leave big, water-habitat snakes undisturbed, else they might themselves ward off desired precipitation (or, I would add, bite you). Finally, it is reported that it was the duty of “scheduled teams of virgin young girls” to scatter traditional, rain-friendly charms on the ploughing fields and footpaths. If still no rain, the next step was often the consultation of divine bones, with each bone having its own name and significance (not unlike osseous tarot cards).

Having never been to Botswana prior to my arrival in early April, I know little about local rainmaking. I know about central Texas rainmaking. It involves turning on a sprinkler system.

Of course, I did not come to Botswana to interfere with the weather, or for that matter to report on anthropological curiosities.

As you all know, thousands of HIV positive children here need medicine to keep them alive, and part of my job is to help see that as many as possible get that medicine.

I have been told by observers near and far that HIV seems too big. I moved from the country with the highest rate worldwide (Swaziland) to that with the second highest (Botswana), and I will say this:

Yes, indeed. HIV is big. Very big.

However, I once heard a small but famous nun say, "If you can’t feed a hundred people, then feed just one."

Maybe, if we are diligent, some day, few will become many. If the conditions are just right, perhaps our relatively small efforts will become big.