Saturday, July 11, 2009


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--

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.

Bush Award

"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:

Telling true stories - A patient encounter

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.


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


“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.

Tuesday, July 7, 2009

Botswana destinations #8: The Khutse Game Reserve

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.

Monday, June 29, 2009

Photo series: The Nile

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

Thursday, June 25, 2009

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

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.

Saturday, June 20, 2009

Photo series: We wish you well

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.