Welcome!

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.

"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

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

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

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

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

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.”

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!"

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

 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)

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)

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

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)

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)

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."

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"

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.”

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

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

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

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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.