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

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

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

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

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

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

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

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

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.

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

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

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

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

“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

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)

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

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

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

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.