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.