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...