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

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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.

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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.