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Reunited in Gondar!

2012-07-10T15:32:00.001+02:00

I arrived in Gondar on Saturday and was reunited with Gelane who has been living here for the last year. Her cousin was graduating from nursing school at the University of Gondar and so her cousin's parents, sister, uncle, neighbor, etc were visiting from Addis for the occasion. They immediately welcomed me into the festivities! First we went to extended family's house in Gondar for graduation lunch. "Fasting" is very common in Ethiopia especially among Ethiopian Orthodox Christians when praying for a certain outcome. I was initially confused when seeing "fasting foods" or "Beyanatu" on menus in restaurants, but quickly learned that "fasting" means no meal until midday and then when eating - no meat or diary products. Perfect for my vegetarianism, because Beyanatu is on most menus in Ethiopian restaurants and is an easy way to explain I don't eat meat. So we had a delicious lunch with Beyanatu for those fasting and meat for the others....

We then went up to Goha Hotel on the mountain overlooking Gondar (the pic at start of blog is from there) for pictures and tea. Like Lalibella and Aksum it rains here most afternoons and when it rains it is pretty cold but during the mornings it is usually pretty warm and sunny. So the Ethiopian tourism commission likes to use the slogan "13 months of sunshine" since Ethiopia follows the Julian Calendar there are 13 months - though i am not sure that slogan works when over half of the day during this season it is overcast and rainy.....Also it is actually 2004 here! And time is different with sunrise (or our 6 am) being 1 am and then the time going from there. Most official tourism things (like flights, store openings, etc) use the Western dates and times but it is still a bit confusing in places like the hospital where sometimes both systems are used.

Interesting spellings are very common

On Sunday we walked around town, going to the market for some Ethiopian scarves, rather than live chickens which were also for sale....

We also went to a traditional Ethiopian restaurant for dinner where several traditional dances were performed. Here is a video of the traditional Gondar dance....

On Monday I went to see Gelane in action at the hospital. She taught medical students on the malnutrition ward. Several of the patients were very severely malnourished - one was 2 years old but was the size, weight, and developmental age of a 6 month old. Medical care is not free here. For malnourished patients formula, plumpy nut nutritional supplements and some other care is provided but when diagnostic tests (blood tests, chest xrays etc) have to be done the patients' families have to pay first. The prices are quite low, but for poor families with nothing, even the slightest fee can be too much. There is some free care for very poor families, but they have to provide documentation from their village leaders of the fact that they are destitute and if they are traveling a far distance to come to the hospital this can often be quite hard to get. Often the resident doctors who are very poorly compensated (3500 Birr or about $200 USD a month) end up paying for tests out of their own pockets!

Today I went to the tourist attractions in Gondar. The castle compound is the main attraction. The first castle (above) was built by Fasildas when he was Emperor of Gondar from 1632-1667. It apparently took ten years to build. The subsequent kings built other castles on the compound because they each wanted to have their own. There was also a house for lions which were kept on the compound, steam baths and a "music hall". I then went to Debre Birhan Selassie church which is famous for the incredible paintings inside. There are more than 100 angels on the ceiling and they were painted 300+ years ago and have not been retouched but remain very vibrant for the most part. Some more photos....

A place of mystery - Aksum

2012-07-08T17:14:00.003+02:00

I flew from Lalibella to Aksum, a 30 min flight where I could choose my own seat and the boarding pass looked like this

No worries they had a hard core metal detector, all (checked and carry-on) bags went through a scanner, and I had a serious pat down from the female security officer.

Aksum is a town with a lot of mystery. The Ark of the Covenant is said to be here (my guide told me God had said for it to be brought to Ethiopia because he knew that Israel would be too unsafe). It is housed in this building

It is guarded by a monk. The monk never leaves the building’s grounds and is the only one to see the Ark of the Covenant. I asked what happens when he dies and I was told that when he is about to die he tells those who supply him with food etc the name and where to find the next monk to stay with the Ark. Only he has not left the area for numerous years (the current one is 50+ years) so he does not really know any other people and hence his choice is actually from God. The are other stories on how the guard is picked – including that all the monks sit and select one. Regardless once selected that person is the only one to see the Ark and never leaves until he dies. Fascinating!

There are two churches on the complex with the Ark, one is the “old church” of St. Mary of Zion women are not allowed in here “because it is a monastery.” I asked what would happen if a woman went in and was told that it would bring very bad luck to that woman – “she might walk in and then completely lose her eyesight!” Yikes, I didn’t want to tempt it so took the picture above from over the wall (the last point where women are allowed). The new church of St. Mary of Zion was built by Hallie Selassie in the 1960s and doesn’t exactly fit in with the surrounds…..

The town is also said to have been home to the Queen of Sheba. This was apparently her palace....

Aksum is also known for its stelae, which are incredible. They were apparently built as tombstones and range in size from 1 meter to 33 meter (though that one is broken on the ground) some are quite plain will others super intricate. A true engineering feat considering that the quarry where the stone comes from is 4 km away and granite is super hard. Each one is a single piece of granite and it remains unclear how they were transported and carved and raised hundreds of years ago.

People are incredibly friendly here which is nice, but makes it hard to go anywhere without being asked for something: "ferenji (which means foreigner or white person) money?", "Ferenji, candy?", "ferenji, pencil?", etc, offered a guide, asked if I want my shoes cleaned, etc.

In Lalibela a typical conversation with a school age child went like this:

Child: Hello

Me: Hi

Child: Welcome

Me: Ames a ganalu (thank you in Amharic)

Child: Where are you from?

Me: America

Child (with huge smile): OH, Obama we love him!

Me: me too

Child: You live in Washington, DC?

Me: no, New Jersey

And then they would tell me about their football team, which needed uniforms (showing me a crumpled piece of paper requesting money). Or about how it was their sister’s birthday and could I give them a shirt to give her, etc.

After having this conversation numerous times I decided to change it up a bit and said I was from South Africa

“Oh Pretoria?”

No, Cape Town

“Oh Mr. Mandela, great man!”

Clearly education of world capitals and famous “good” leaders is working in Ethiopia (interestingly there was no mention of Bush or Zuma…..)

All over Ethiopia, students graduated from University yesterday. So on Thursday and Friday they dressed in their graduation gowns and walked around the town taking pictures. As I passed a group of them I said "congratulations." We had a short conversation about what each of them had studied and then they requested that I take pictures with them. I agreed, figuring it was the least I could do after spending all this time taking pictures of their town and its inhabitants. I thought we would take one group shot but then they each wanted a private one. After they took many with their cameras, I had them take one with mine.

There are also ping pong tables and foosball tables all over town, on the side of the road. These guys asked me to play with them as I passed by. Unfortunately I only got a pic of them playing.

Lastly, anyone who has ever seen me eat Oreos knows that I really only like the cream filling and often only eat that part, or at least scrap the filling off and save it for last. This monkey was a pet of the cafe in one of the local parks, I had some "biscuits" with cream filling which I had bought as a snack and my guide suggested that we give the money a few. The monkey gladly took them and proceeded to lick the cream filling off and leave the cookie part to the side!

Where have I been? Where I am going?

2012-07-04T10:21:00.001+02:00

Last Sunset over Camps Bay

I realize it has been WAY too long since I have updated this blog, so probably no one is reading it anymore ;) The "why" is multi-factorial. For one, there is facebook which makes it easy to just post a quick update and some photos and not feel like I have to write a whole story, but I realize not everyone is on FB. Secondly, I have been having a rough couple of months from a work prospective and I like to keep the blog relatively positive so haven't felt like there is so much to write. Lastly, I have decided to move back to the United States (for now ;) and planning that transition has been consuming a lot of time.

One of my last trainings at the "African Cave Lodge" in NW province South Africa, it is really cave like.

We taught the nurses and lay counsellors to calculate the adherence of patients taking ARV medications

We also taught them a color coding system useful for patients who cannot read and write to make drawing up medications easier

After spending the last year doing mentoring and training of local nurses, doctors, and lay counsellors on pediatric HIV, I have realized how much I miss clinical work. I do enjoy teaching and training, but I need more of a balance. I miss having patients. I also feel that while "capacity building" should be the gold standard of global health work, building true capacity is quite hard when many of the barriers are secondary to mismanagement of resources, lack of infrastructure, and shortage of health care workers. It is also really hard to show that all this training and mentoring is making a difference. Ask me about this next year and I may be able to give you a different perspective ;) Regardless I have decided to return to St. Christopher's Hospital for Children in Philadelphia (where I did my residency) and work as a general pediatrician. That patient population served by St. Chris is quite diverse and I am excited to serve those patients again and to be able to put my Spanish (which is now quite rusty) to good use.

Before going back to the US, I decided to take advantage of the fact that I was already in Africa. For the next month, I will be traveling around and attempting to see more of this incredibly diverse continent. I started in Ethiopia. After a day in Addis Ababa, I traveled to Lalibela which is known for its rock hewn churches. In the 12th and 13th century King Lalibela wanted to create a "new Jerusalem" in Ethiopia and apparently instructed workers on the construction of 11 churches. The churches were carved from the rock with hammer and chisel - an incredible feat. In the Ethiopian orthodox tradition, coming to Lalibela is just as holy as going to Jerusalem and during holy days thousands flock to the town to pray. All of the churches are incredibly crafted especially when you consider the tools that they would have had at their disposal. Of course pictures are worth a thousand words so here are 50 or so of them....

Tomorrow I head to Axum for 2 days and then Saturday on to Gondar where I get to see Gelane for a few days (unfortunately my work permit ended and I had to leave South Africa during her already planned trip to the US) but we still get 5 days to see each other. Then I will fly to Tanzania where I hopefully get to see Tecla (my anatomy lab partner from first year of medical school!) and then Zanzibar for a weekend. Finally I am joining a Nomad Adventure tour which will be an overland trip from Dar to Victoria Falls - 11 days of camping across Tanzania, Malawi, Zambia, and Zimbabwe. Finally on 28 July I will fly back to the US and begin my transition back into life "that side."

A Tribute

2011-12-12T21:58:00.003+02:00

At my medical school graduation

My grandmother passed away 2 weeks ago. She had just turned 88. She lived a long and mostly happy life, but had not really been physically able for the last few years and was very sick for the last few months, so it was her time. A few months ago she had a major stroke which prevented her from saying more than "Hi" and causing her to become very frustrated that she could not express herself. Despite knowing that it was for the best, losing someone you love is never easy. Being 7,800 miles away did not make it any easier. She was incredibly proud of her 3 sons, and their partners, and her 4 grandchildren. She loved to brag to her friends, and anyone else who would listen, about what her children and grandchildren were up to. She was an avid reader of this blog, when she was able and later liked to have it read to her by my father and look at the pictures. So I thought it only fitting to have a small tribute to her here.

Sonia Scherzer (Sunny as she was called by everyone, Grandma to me, and Grandma Beady as she was aptly named by Daniel (and later Sarah) - for her love of beaded necklaces) was a wonderful grandmother.

Trying on the cap and gown with her four grandchildren

Though she was clear that she would have preferred for everyone to live and work in Queens so she could see them everyday, she was also proud that her offspring were globetrotters (some of us more than others). She herself loved to travel and lamented the fact that she was not able to visit me in Africa – one of the few continents she had never been.

I can only speak for the last 31 years of her 88-year life, but I feel so lucky to have gotten to know her so well. I think all would agree that Grandma was a very opinionated, strong willed person who could be very demanding at times, but she was also an incredibly honest, loving, and kindhearted person. She could, and would, talk to anyone and everyone, and random strangers always felt comfortable telling her everything. I remember several times when I met her in NY City after she had taken the bus in from Queens and she would tell me the life story of the person who had sat next to her on the bus ride in. Inevitably they would have shared their problems with her and she would have provided suggestions to them. She would go on elder hostel trips and easily make new friends. On our trip to Israel together, when I was 13, I remember how easily she became good friends with the other grandparents. Though she was at times sad that she was one of the few single grandparents on the trip, she never let that stop her. For most of her life she had a very active social life of bridge games, dinners out, movie nights and scrabble. Social work was definitely her calling, and though she was officially retired in my lifetime, she continued to provide “counseling” and advice to her friends and also to random strangers.

She was an avid reader and loved to recommend books for me to read and get recommendations from me, we shared a love of Jodi Picoult books. She was a big tennis fan as well and could watch the tennis channel for hours on end, though at the end of her life she was not always sure who was playing, it didn't matter to her. I will always have fond memories of playing tennis with her in Florida and upstate NY. Even though I was never particularly good at tennis, she never gave up on me and was happy to play and give pointers. She had a supreme patience for board games and was happy playing hours upon hours of Monopoly or other such games with her grandchildren.

We also shared a birthday month and it was often jointly celebrated during Thanksgiving.

She was also an avid knitter and needle pointer. She, and my mother, taught me to knit and needle point when I was 8 and she passed her love of knitting to me for sure. She always wanted to know what I was knitting and in the last few years was excited to share her comments over Skype. She did not get to see my last few knitting projects, when I have branched out into toys....

Over the last 10 years she was so lucky to be expertly carried for by Maxine, and in the last 2 years Charlene and Dimples as well. Though she was certainly not an easy patient, and not always the best at showing her gratitude, she did appreciate the loving care she received from them and I know she was very thankful that their care (and the devotion of her sons to her wishes) enabled her to stay in her home rather than having to be in the hospital – a place she hated more than any other! The devotion of her sons to caring, visiting (even coordinating schedules to make sure that someone was there at least once a week – and usually more frequently), and making sure that her wishes were carried out was a true tribute to her and a great example for me and the rest of her grandchildren.

At Aaron's college graduation

She will continue to live on in all of our memories and actions. For me she will be ever present in my love for knitting, my inability to have dry eyes at special occasions (happy or sad), my strong-willed sprit, my love for travel, and my pride in and commitment to my family. Grandma you will be missed, but most definitely not forgotten. We all love you.

A Race!

2011-11-06T17:16:00.001+02:00

I used to say I would never run. I also said I would never wake up early to exercise! Well all that changed last year. After walking the 10 km race at the Soweto Marathon, I saw an announcement for the Gaborone Marathon at which there was also a 10 km race (but only a run). Long story short, I was talked into training to run it. I realized that anyone can run if you run slow enough (my run is definitely more of a jog ;) I also realized that in Botswana the only time when it was cool enough to run outdoors in the summer was just after the sun rose (before it had time to heat up the day). So crazily I began to get up early to train. Things were going well until a few weeks before the marathon when it was canceled! Of course, this was after I had already paid my 50 pula (around $8) and I was told that there would be no refunds - just an entry into next year's race. Anyway it was sad and I decided I would have to try again. Upon moving to Cape Town, I began running again, this time at more normal hours (after work) as it is not as hot here! I decided to RUN the 10 km race in the Soweto Marathon. This year on November 6th I did just that! I had one goal - to run the entire thing (not to walk any parts of the race). Despite several large hills, I managed to achieve my goal and to run the 10 km in 1 hr and 10 min which I was happy with (you might remember that I walked it in 1 hr and 35 min, so I really don't run much faster than I walk, but still ;)

My friends Jacquie and Shikata drove down from Botswana to meet up with me and run the race as well. We made a nice weekend out of it. We stayed in the same B+B in Soweto as we did last year. We went to the Apartheid Museum and though I had been once almost 2 years ago, I still managed to learn a ton. We also went to Nelson Mandela's house in Soweto. Of course, he did not actually live there very long before being sent to Robbin Island but Winnie Mandela and his children lived there while he was in prison. Unfortunately it was burned at one point so there is only one original table (it had been leant to someone else and they got it back afterwards). The house has a random collection of various citations and awards that the Mandelas have received over the years. Including "the key" to the city of Newark! There is also the tree in the backyard under which all of the Mandela's children and grandchildren's umbilical cords have been buried. Jacquie and Shikata dropped me off in Pretoria for a week of working that side, before heading back to Botswana. So we stopped at the Union Buildings as well. The Union Buildings were designed by Sir Herbert Baker in 1910 and were the site of many marches and protests over the years. Today it houses the offices of the Presidency and Presidents (including Nelson Mandela, of course) are inaugurated at the Union Buildings.

This is Jacaranda season. Pretoria is known for it's Jacarandas, in fact it is called Jacaranda City because there are so many lining all the streets that the whole city looks purple during this time of year. It is quite pretty.

The race was followed by a week in the Northwest Province. In addition, to our regular visits to the clinics, Carolin (one of the South to South nurses) and I conducted a two day training for nurses in the Province. We were supposed to have 11 people, but due to staff shortages we ended up with only 6. It was unbearably hot (40C/104F) and the room we were in had no fan or anything! It was a challenge for the participants to stay awake, however we did manage to get them to do some group work on cases to stay awake. It is really incredible the conditions under which nurses here work and a true testament to their commitment to their patients!

Here is a slideshow of the week's events:

Bo-Kaap

2011-10-24T22:00:00.000+02:00

Believe it or not, there is Groupon South Africa! When I saw a coupon for a cooking tour on there, I knew it was meant to be. Who doesn't want to learn how to make Cape Malay Curry, Chili Bites, Samosas, and Roti? So on Saturday I headed to Bo-Kaap, a 15 min walk from my house. The neighborhood is full of colorful houses and home to much of the Cape Malay population in Cape Town. The Cape Malay community are descendants of slaves brought over from Indonesia, Malaysia, other parts of Asia, and the Middle East by the Dutch East India Company in the 16th and 17th centuries. Cape Malay is actually not a correct term as many are not from Malaysia, but they were all clumped together by the Dutch. Many practice Islam and the Bo-Kaap area has many mosques today (though they were originally not allowed to practice their own religion, they were able to maintain it).

We (a group of 16 South Africans and me) were met by Zainie at the Bo-Kaap museum (which has a small exhibit on the history of the area). She gave us a brief orientation to the area and some of the history and then took us to the famous Atlas spice shop which has supplied the community with the essential spices for years. She pointed out some the essentials and then we walked to her house a few blocks away. Walking down the street we were greeted by the aroma of delicious smelling curry and knew we were headed in the right direction (she had already spent the morning preparing chicken curry since the group was so big).

We started by making Rotis. Basically flour, water and oil but then after they have "risen" a bit you roll them out in a special way, spread butter on them, roll them back up, freeze them so the butter sets, roll them out again and then fry them! Quite a process, but it results in buttery goodness. While the rotis were rising we start on the chicken curry, but she instructed me, and the other vegetarian, on how to make a butternut squash, carrot, lentil curry that was delicous! Then we made our own samosas, quite fun to fold. And chili bites as appetizers. After 2.5 hours of cooking we sat down to a spectacular meal. At the end we each got a recipie book and a starter package of spices to go home and try for ourselves! Looking forward to attempting it one day soon ;)

Here is a slideshow of photos (have to go to the actual blog for the slideshow as always ;)
The first few pictures are of a movie set next to my house. No photos were allowed when they were actually shooting, but they stopped filming on Friday. On Saturday morning as I made way to Bo-Kaap, I noticed that the set was still there. So if you every see The Great Britian Story you might recognize something from these photos and will know that it was filmed next door to my apartment complex ;)

Hikes

2011-10-18T22:44:00.000+02:00

20 years ago if you asked me to go on a hike, I complained, had to be bribed with M+Ms, and "hated" it! I am also NOT a morning person. So many would be surprised to learn that I agreed to wake up at 6 am last Sunday for a hike! My how things change, as I now love hiking ;) But really, who could refuse a hike with views like this one?

When people think of Cape Town, they often think of Table Mountain, but Table Mountain is actually one mountain in a whole mountain range and there are tons of awesome hikes. One of the participants, Allan, who attended the training that I conducted last week, asked me if I wanted to join him and a few of his friends for a hike. I would have preferred to start a bit later in the day, but people here like to get up early. We drove to Noordhoek, a suburb of Cape Town and ended up hiking for 4 hours. It was a beautiful day and we were joined by two gorgeous and super well behaved dogs. We went along the trail at Silvermine and ended up in Elephant's Eye cave (which is where the picture above was taken). From there you can look out on the Southern Suburbs of Cape Town. Interestingly it is a great view of Pollsmoor Prison (an infamous high security prison in South Africa) which is situated right next to an extremely posh golf course community! How is that for interesting zoning?

Here is a slideshow of the day:

The previous Sunday I also went hiking. This time up Table Mountain. I have been up Table Mountain a few times, but always on the cable car. It was probably not the best idea to try to hike it the day after fasting for Yom Kippur when it was 90+ degrees out, but I made it. I went with Bev (who I met at a Rosh Hashanah dinner) and her friend Jon. It was nice that I got to attend services this year for Rosh Hashanah and Yom Kippur, though it did make me miss B'nai Keshet and it's fabulous co-presidents even more ;) We went up the most direct route which is basically straight up and it is in the sun the whole way. It was a rough hike and next time I will make sure to drink water and eat the day before ;) But it was worth the sense of accomplishment at the end!

Here are some photos from that day:

Heritage

2011-10-06T22:54:00.001+02:00

September 24th was Heritage Day in South Africa. September 24 used to be Shaka Day in KwaZulu-Natal (a large province along the Eastern coast of South Africa) in commemoration of King Shaka (an influential Zulu king). After the end of apartheid it was not initially included in the public holidays bill, but the Inkatha Freedom Party, a political party representing a lot of Zulus, objected to the bill without the Sept 24th holiday. As a result, a compromise was reached and the holiday was renamed "Heritage Day" and made into a public holiday in 1996. The holiday is intended to celebrate "the rainbow nation" and all the diverse cultures which are represented in SA. A nice idea. Recently many people have started calling it National Braai Day since Braaing (or BBQing as it is called in the US) is certainly a part of the culture here. Everyone loves to have a Braai.

What it met for me was that all the government run museums in the city were free for the week! So I took advantage and decided to explore a few of those which are literally in my front yard. I went to the South African Museum which reminded me of the National Museum of history in NY (large skeletons of whale, mineral collection, etc.) I also visited the South African National Gallery which had some interesting art. And the Castle of Good Hope which is the oldest building in South Africa. It was built on behalf of the Dutch from 1666 to 1679. It was complete with torture chambers and a posh palace for the governor which has turned into a museum of artwork and antiques. Imagining some of the awful things that I am sure went on in the Castle was a sobering experience.

Some photos from the day....

Education?

2011-09-24T22:56:00.000+02:00

I have been volunteering with a group called Equal Education here in Cape Town. They are advocating for improvements in the education system in South Africa. During the Apartheid era, education of Blacks was called Bantu education and was specifically designed as a separate and unequal system (interesting that this system was implemented just as the similar system in the US was being deconstructed). I think Bantu Education is pretty well summed up with this quote from Hendrik Verwoerd (The Minister of Native Affairs in 1953 when the policy too affect):

"There is no place for [the Bantu] in the European community above the level of certain forms of labour ... What is the use of teaching the Bantu child mathematics when it cannot use it in practice? That is quite absurd. Education must train people in accordance with their opportunities in life, according to the sphere in which they live."

Obviously, this system is hard to undue. After 4 decades of inferior education, the damage cannot be undone overnight. Still most of the current teachers in Black schools, (although they are not officially segregated anymore, they are largely segregated by where people live), were educated in the Bantu education system and are not really qualified to teach the new education curriculum. The schools are overcrowded, many lack proper sanitation facilities, and 92% of South African public schools do NOT have libraries! Equal Education is an advocacy group that "advocates for quality and equality in the South African education system and engages in evidence-based activism for improving the nation's schools." You can read more about them here: http://www.equaleducation.org.za/what_is_EE

One of their many projects is to work with schools to create libraries. Most of the schools have a space called a library, but they don't have books, librarians, computers, etc. So Equal Education collects books and donations and has already opened about 14 libraries. I have volunteered with them a few Saturdays in the past few weeks to sort, cover (the books are mostly paperback so they are covered in clear contact paper to increase their lifetime), and catalog books. Today was the opening of a library in Khayelitsha (the largest Township in Cape Town - 1 Million people!) It is at Matthew Goniwe Memorial High School. The opening was quite moving. The program started with a learner performing a poem about the principal and her work to improve the school.

Then the principal spoke about how the school had gone from being in the news for the wrong reasons (two separate stabbings of students in 2005 and 2006) and now was classified as the best high school in Khayleitsha! She spoke about her efforts to create a book club of teachers and students (with the help of Equal Education and a local bookstore). She was told to select 15 students, but had 25 who were interested and qualified after visiting only 5 classes in the school and had managed to get all of them included. And how she and all the learners were so excited about the library.

Next 4 learners performed a scene from a book they had read and a small group sang some beautiful songs (not the best quality video recordings, sorry).

And then the ribbon was cut and the library officially opened. The learners quickly filled the room and went right to the books. They began taking them off the shelves, reading them, and sharing lines with each other. It was clear that the library will be well used and a much needed resource in the school.

Row of outhouses

After leaving, I drove around the township a little bit. Rows of shacks, poorly maintained roads, lines of outhouses, crisscrossing electricity wires (as there are many illegal electricity connections), and trash abound. I can only begin to imagine all of the struggles that students from this environment face everyday! But I hope that having a library, and the ability to take books home, will at least make a small improvement in their lives.

A slideshow with some other photos from the day:

Trainings, Wine Tasting, Visitors, oh MY!

2011-09-18T23:26:00.000+02:00

Sunset over Table Mountain

It has been a busy few weeks! The first weekend in September there was a festival called Franschhoek Uncorked in the winelands (Franschhoek is the name of one of the wine routes near Cape Town). Marina, a previous South to South epidemiologist who now works for a PEPFAR funded project in Pretoria, invited me to join her and two of her friends for the festival. We hired a driver (so no one had to drive home after a whole day of wine tasting) and toured 5 different wine estates. Each estate had a different theme for the weekend, with music, food, and of course wine tasting. We had a lot of fun.

Here we are with the Champagne (well they can't actually call it that, since it's not made in France) that Obama had at his inauguration!

With the "mariachi band" at one of the wineries which was having a Spanish themed day. (Of course none of these men were actually latin and my rusty Spanish was better than theirs but it they sang and played well.....)

The first week in September I helped conduct two trainings. The first part of the week I was at a training at Tygerberg Hospital. South to South conducts these trainings once a month. Doctors (and a few nurses) come from all over South Africa to spend 5 days learning about pediatric HIV. They purposely keep the training groups small (no more than 12) to encourage participation from all group members. Many of the trainings are taught by South to South staff and then other specialists are brought in from Tygerberg Hospital to contribute as well. In addition, the participants get to shadow in the children's HIV clinic at Tygerberg and spend time on the pediatric ward at Brooklyn Chest Hospital (where children with complicated tuberculosis infections are admitted). Since it was my first training, I spent a lot of the time observing and taught one lecture on the HIV medications. It was nice to have such a participatory group, makes teaching so much more interesting! On Thursday and Friday, South to South was also conducting another training for one of our collaborating agencies so I went to help with that. We had 35 doctors, nurses, pharmacists, and pharmacy assistants at the two day basic pediatric HIV training. We were able to split them in two groups, and I got to work with the nurses. We had many lively discussions and though it was brief, I think they were able to get comfortable with the basics.

Along Chapman's Peak Drive

Most excitingly my first visitors in my new apartment arrived! My first visitor in Cape Town was actually my college roommate, Kerry. She was traveling around South Africa and visited Cape Town shortly after I arrived. We spent two days talking and catching up, as we had not seen each other in a few years. Unbelievably, we did not take any pictures together! Crazy, but I think we were so busy talking that it never occurred to us. Last week my brother, Aaron, and his girlfriend, Jen, came to visit and Aaron made sure that there was plenty of photo documentation! He took more than 1,000 pictures in 5 days!!! It was great to see them and to get to show them Cape Town. We went to Cape of Good Hope (the most Southwesterly tip of Africa), drove Chapman's Peak (beautiful costal views), took the Cable Car up Table Mountain, and ate lots of good food. They got to go wine tasting and see Robben Island while I was at work. We also discovered some new things, most importantly a Saturday market at The Old Biscuit Mill in Woodstock (a neighborhood in Cape Town) which sells amazing prepared foods, cheeses, homemade wines, paella, etc, etc. I even went back this weekend and think I will make it a Saturday morning tradition of sorts ;)

Me and Jen on the beach at Camps Bay for sunset!

Here is a slideshow of some of the best photos taken by Aaron (and a few by me and Jen) - hard to pic out of a 1000, but don't worry there are less than 60....

Moretele

2011-08-28T18:40:00.000+02:00

So the big question is what I am actually doing at work? Well, last week I really got to find out! It was my first "implementation week." Basically South to South is working with the departments of health in the different provinces to help them improve their pediatric HIV care. Since things in the Western Cape (the province that Cape Town is in) are already decent, most of our work is in other provinces (there are 9 in the country - sort of a similar concept to states in the US). Right now we are working in the Northwest Province in a sub-district called Moretele (it is blue thumbtack below - you may have to zoom out a lot to get prospective, if it doesn't stay zoomed out)

View Moretele in a larger map

Moretele is about 1-2 hours from Pretoria depending on where in the area you are going and how much rain there has been (since many of the roads are dirt roads, when it rains a lot there is a bit of a problem getting around. Luckily it is dry season right now ;) There are 26 clinics in the area and we are focusing on 10 (as requested by the department of health). Only 4 of them currently supply ARVs to patients (and 2 just started this month) the rest of the patients who are HIV positive must travel to one of those clinics to get care, which is an improvement since they used to have to travel to the nearest hospital which is not even in their district. The clinics are pretty far apart considering most people do not have cars, bikes, or donkey carts and public transportation is limited to minibuses....Many of the clinics do not have running water. Most of the clinics have a severe chair shortage so meetings are held either standing up or on the beds in the labor room (when there are no patients in labor). So what we are doing is helping the nurses, lay counselors, and the few doctors and pharmacists develop their skills and comfort in treating pediatric HIV. We are also focusing heavily on PMTCT (Prevention of Mother to Child Transmission) since that is really the only way to stop pediatric HIV. Some of the time is spent mentoring individual health care workers and the other part is helping the clinics put systems in place to improve care.

A typical sign listing the services at the clinic - though most are supplied by nurses only and many patients have to be referred to the hospital for further management which is hours away. There is an ambulance in the area most of the time for emergencies though it can take a long time to arrive (and if it is not a life threatening emergency they have find their own transport, which many of them cannot afford)

On Tuesday, I got to attend the second meeting of the Teen Club in one of the clinics. There were 11 teens (a stark contrast to the 200 who attend Teen Club in Botswana every last Sat of the month). But this is the beginning. The teens got to know each other, elected members to do different tasks, and discussed the importance of confidentiality. I am looking forward to working with the social worker at the clinic to help her develop the Teen Club even further, but it is off to a great start. The kids were really engaged and clearly appreciated being able to attend.

The road to one of the clinics

South to South (S2S) has created registers (basically like patient logs, where healthcare workers enter information about the patients and columns like "mother on HAART y/n" prompt the healthcare worker to ask certain questions and send certain tests). These have helped to improve the numbers of women who are receiving ARVs when they are pregnant and in labor. But we realized that some of the health care workers do not really understand why they are doing certain things - they are just following protocols. This is generally good except that without understanding the reasoning behind the protocols, they are often missing things. So on Wednesday one of the S2S nurses and I sat with all the nurses in one of the clinics and explained the reasoning behind some of the protocols to them. It was so nice seeing the lightbulbs go on in many of their heads.

I will be going to this district 1-2 weeks each month for the next 6 months and then we may expand to other districts depending on how things are going in Moretele. In between traveling weeks, I will work on projects identified while there (this week, improving their adherence sheets, collecting resources for the teen club, and improving the registers). And also conducting week long trainings at Tygerberg Hospital at the University of Stellenbosch (first one for me is Sept 5-9).

One of the clinics we visited is trying to make the outside look nice so all the workers at the clinic each brought a plant and they were planting and watering when we arrived.

On one of the days we visited a business of local women called the Heartfelt Project during the lunch break. It was started by a woman named Martha after her son was wrongly accused, imprisoned and died in prison. She lost all of her money to a corrupt lawyer who had promised to get him out. She had worked for 20 years for a family in Pretoria and their daughter, Julie, helped her start the business. Now they have 10 employees and create all sorts of hand sewn felt designs. If anyone is getting married (or having another occasion to party) and needs nice party favors, consider ordering some from them they are great and the profits go to the women and also to support a local community health project. .....www.theheartfeltproject.com is where you can read more about them and place orders.
They will even ship all over the world with enough time ;)

Here are some of the designs before being sewn and stuffed.

Hope everyone reading this on the East Coast is managing to stay dry and get back your power! Stay Safe!

Larry Joe

2011-08-19T20:27:00.000+02:00

A few days ago I was invited to hear a guy called Larry Joe perform at a local synagogue. I had never heard of him and so I googled him before going and thought he sounded good. Also I thought he must have an interesting story since the songs online were recorded in prison! But beyond that, I had no idea what to expect and I was truly inspired by him and his story.

He was introduced by Aron Turset-Swartz (a founding and now former member of the band Freshlyground. Aron said that on World AIDS Day (Dec 1) in 2008 Freshlyground was asked to perform at a small concert in Douglas, South Africa (in the middle of the country). As the sound equipment was being set up a man came on stage and performed two songs which both got a great reception from the audience. Aron remembered being struck by how great the guy sounded and he asked him who he was and where he was from. "I'm Larry Joe from the Douglas Correctional Center," he said pointing to the side of the stage where 4 armed guards were waiting to take him back to prison. To make a long story short, after the concert Aron developed a relationship with Larry and eventually ended up becoming his producer and helping him to record his first CD.

Then Larry took the stage and began to play his guitar and sing his original songs in 5 different languages! I thought he was really good. In between songs he told his story. Basically, when he was in his early 20s he broke into a few houses in Kimberley, South Africa. When he heard the police were looking for him, he ran away to Cape Town. He had learned how to play a few chords of guitar from his father and liked to sing. He begged for money until he had enough to buy a guitar and then began to sing on street corners around Cape Town. He did this for 7 years and got better as he went, always singing covers. One day he had a dream that he was playing in Madison Square Garden and he decided that he could not really pursue a music career until he served time for what he did. So he returned to Kimberley and turned himself into the police. He was sentenced to 5 years in prison. While in prison he used the time to improve his musical skills. He began to write his own music for the first time and wrote over 40 songs in 5 different languages. He only really speaks English and Afrikaans, but he had guards and other inmates translate some songs into Xhosa, Spanish, and Portuguese for him. In addition, he says he read every book in the prison library and used those to inspire his songs in other languages.

Here he is playing with Aron backing him up on a wooden box as a drum

The prison was incredibly accommodating of his desire to practice and play music, allowing him to play in his cell, asking him to perform at that World AIDS Day Concert, and eventually letting Aron bring in recording equipment so that he could record his first CD from inside a cell in the prison. They were apparently so accommodating because they want to aid prisoner rehabilitation and they saw this as a great opportunity for Larry.
He was released on parole on December 13, 2010 and his CD was released that day as well. Now he goes around to schools, prisons, and other community organizations to sing and tell his story in the hopes that he can inspire young people to follow their dreams. Definitely an inspirational story!
Here is a link to a video about him so you can hear him sing
http://www.youtube.com/watch?v=EQgXj1s1sQ4&feature=related.
If it doesn't work just go to youtube and search for Larry Joe.

On a totally unrelated note, for your entertainment purposes, I am going to include the following picture of me and my bosses.

Elke (Pediatric Unit Manager), Liezl (South to South Clinical Director) and Me

What is so great about being in pediatrics is that pediatricians are generally fun. Elke and I are both new to South to South (though Elke started 2 months ago). So at our staff meeting, Liezl welcomed us into the organization by giving us each a pair of eyeglasses made from wire. This is because now we are joining South to South and their vision for better pediatric care for children. Each previous staff member has also gotten to go through this ritual. We then got to decorate them with ribbon and beads (you can't really see the beads which form the side of the glasses, but trust me they are there ;)

Slideshow reposted

2011-08-17T18:53:00.000+02:00

Apparently there were problems viewing the slideshow on the last post. I hope this one will work better....

If still not working, click on this link to view https://picasaweb.google.com/109170280186909692299/August142011?authkey=Gv1sRgCIP3oJeSv6LB2gE

Settling in

2011-08-16T23:01:00.000+02:00

Now that I have been in Cape Town for 2.5 weeks, I am beginning to feel a bit more settled. I am working in Bellville which is one of the Northern Suburbs of Cape Town (30 km and about a 30 min drive from the city center). It felt too suburban and too segregated for me to live there, so I decided to live in Cape Town itself. But since choosing an apartment over the internet is hard anywhere, and esp difficult when you don't really know the city very well, I decided to wait until I arrived to find a place. For the first two weeks, my work arranged for me to stay in Bellville in a self-catering apartment which was a 10 min walk to work and 10 min walk (in the other direction) to a shopping center. So after a 36 hour trip (through Dubai), I was met at the airport by my super nice co-worker who took me to the local Pick and Pay (grocery store) and to the apartment. The next day I rented a car (my first time driving a manual alone, more on that later) and began apartment hunting. In 2 days I must have looked at 20 apartments (some in Blouberg - along the beach and the rest in the city). I decided on a place in center city right across from Company Gardens. The big blue thumb tack below marks the spot of my building (this map is in my grandfather's honor), if you click on the map you can zoom in and out to get a better sense of where it is....

View St. Martini Gardens in a larger map

It is completely furnished which saves me a lot of hassle. Parking is under the building and it is walking distance to tons of great restaurants, shopping, a lovely public garden, etc. I got a 2 bedroom apartment so there is plenty of room for visitors ;)

A slideshow of the first 2 weeks (if you are reading this on email you have to go to the blog to see the slideshow)....

Which brings me to the car! I did not know how to drive a stick shift before I got to Botswana but last year I learned under the tutelage of Gelane and Bri on our many trips for our outreach evaluation. And after our trip to Swazi/St. Lucia, I was feeling pretty okay with stick. Only a few small problems here: HILLS (and very steep ones), lots more people, stop and go traffic.....all these things make driving a stick shift much harder, esp when you learned in a flat, sparsely populated country. So let's just say that driving stick when I rented a car was interesting and I was thinking that my life would be simpler with an automatic car. However those are hard to come by, more expensive, harder to get fixed and harder to sell. As a result I ended up with a Nisaan Micra (ever hear of that one?) I think it looks like a bug, but it is nice and small (good for parking around here), supposedly light on fuel (it better be considering it cost me the equivalent of $45 for 3/4 of a tank!!!!), and relatively peppy on the highway considering it only has a 1.4L engine! So far so good, I am getting better on the hills and each day feel slightly more comfortable driving stick....though I still don't understand the appeal when automatics are so easy.

So far work has been a lot of logistics as well. Familiarizing myself with guidelines, protocols, training manuals etc. They have developed a great pediatric toolkit to help healthcare providers when they are treating children with HIV. It was developed for South Africa but now is being changed to be more generally based on the WHO guidelines so it can be used in many other countries, so I helped with that process. All my colleagues are very nice and friendly and it seems we will make a good team. My first mentoring trip is next week, so I will have a much better sense of things by the end of the month.

One thing I have seen here are the incredible disparities, which I am sure I will see even more of when we go up to the Northwest Province where we are doing the mentoring. The city is very modern, has good infrastructure, plenty of pretty buildings, and tourist attractions. However, though apartheid ended 17 years ago, there are many lasting effects still present today. Residential areas are still incredibly segregated. In fact, when I called real estate people looking for houses, I talked to one agent, over the phone, who told me "that area is not for you." I asked him what he meant by that and he said "Trust me, I try to match the right people with the right houses." I had never met the guy, but I am guessing that he could tell I was American by my accent and probably just assumed I was white based on that. I never met him, so I was unable to investigate his reasoning any further.

The inequities are everywhere if you pay even a little bit of attention. When I was moving into my apartment, I had several boxes of things shipped from Botswana to Cape Town. They arrived bundled together in a giant cardboard box. As we were unpacking the giant box in the truck in front of my building, the guard for the building was keeping watch. When we had all the smaller boxes in the apartment, he asked me if he could have the giant cardboard box. Of course, I said yes and then just because I was curious I asked what he planned to do with it. "Take it to Khayelitsha [the largest township in Cape Town] and use it to cover my shack since it is so cold," he told me. Here I was unloading boxes of clothes, blankets, knick knacks, etc and this guy was trying to get some extra insulation for his shack. Having driven past Khayelitsha and other townships, I have seen the condition of housing there, but I naively assumed that most of the people living in shacks were some of the 25% of the population who are unemployed (a shocking number that I read in the paper this morning). In fact here was the guy who is working 12 hours a day, 6 days a week as a guard of a big apartment complex and he too is living in a shack. The disparities here are even greater than in Botswana where, though there is definitely extreme poverty, people who are working can generally afford something more substantial than a shack. Highlights once again how far there is to go to overcome decades of forced segregation and oppression and how fortunate I am.

Flashback: Bushfire and St. Lucia

2011-08-09T20:00:00.000+02:00

Enjoying the music at Bushfire

Bushfire is an annual music festival in May Swaziland - 3 days of live performances from all over the world (though most performers were from Africa). Gelane, Premal and I missed it in 2010 so we had been planning to attend in 2011 for some time. Then realizing that there was a Botswana holiday the same week, we decided to make a week of it and explore the Eastern coast of South Africa with Bri joining us there. We got off on a bit of a bad start. We drove from Gaborone to Pretoria in Gelane's car and then realized that the radiator was leaking. We took the car to a Honda dealer and they said the radiator needed to be completely replaced.....We spent several hours in the Honda dealer (during which I finished the handwarmers I had been making for Gelane)...

Gelane testing out the new hand warmers and praying that they would be able to find a radiator in the area!

Unfortunately they were not able to find the radiator in the area and told us that the car could not be fixed until Tuesday (it was Friday and bushfire was Friday-Sunday in Swaziland which was still a 5 hour drive away!) So we went into planning mode and to make a long story short - headed off in a rented Nissan Hardbody truck (with manual transmission)! We needed such a big car since we had so much stuff (below is Premal in the rental agency with all our stuff....)

We finally arrived in Swaziland at night and managed to put up our tent in the dark (Premal got really into hammering in the stakes - below) before heading out to experience the music.

For 3 nights and 2 days, we were treated to some amazing performances. We camped right next to the area where the stages were and it was great to be able to come and go as we pleased.

Here is Gelane in the midst of the crowd in front of the stage

It was gorgeous during the days and pretty darn cold at night, but thanks to Liz and Jon's awesome tent and camping equipment we managed to stay pretty warm.

Oliver Mtukudzi was definitely our favorite. He is in his 60s and still was jumping around the stage and has an amazing voice!

There was one artist from Botswana, Shanti-Lo, who we also really enjoyed.

When the concert finished we drove through Swaziland (it is a tiny land locked country surrounded by South Africa). We stopped at the Swazi Candle factory where we saw intricate candles of all kinds (from elephants to birds to larger circular creations - these people were talented with wax) being made.

We watched this entire rhino be created and it only took about 10 minutes!

Next stop was St. Lucia - no not the island in the Caribbean! There is a beach town along the Eastern Coast of South Africa called St. Lucia. It was a very sleepy beach town (esp. because it was not high season). Which meant we had a gorgeous beach to ourselves and plenty of room for the requisite jump shots ;)

We even went snorkeling one day though the water was extremely cold and the waves were pretty rough. After freezing a bit and getting bashed by the waves, Gelane and Premal spotted a small tidal pool and decided to try it....

The town is basically in the iSimangaliso Wetlands Park which provided for some amazing views and landscapes as well as excellent animal spotting on our self-drive safaris. We saw rhino, buffalo, giant kudu, and then on a boat cruise we were super close to Crocs and hippos!

Here are some photos from the boat cruise

Bri, Gelane, and I even got to go scuba diving in Sodwana Bay which is bit further North of St. Lucia and as extremely clear waters with tons of beautiful fish.

All in all an amazing last trip from Bots!

Flashback: My Last Teen Club :(

2011-08-06T16:33:00.000+02:00

When teens are asked what topics they want to learn about at Teen Club, sexual issues are often first on the list. There are numerous myths and misconceptions all over the world when it comes to sex. This is especially true in a conservative country like Botswana where teachers, caregivers, and even some healthcare workers are reluctant to talk openly with teenagers, deeming this topic inappropriate and unnecessary for adolescents. I was asked to play an active role in planning a Teen Club about sex so that the Teen Club staff could make sure that all the information which was presented was medically correct. The planning sessions became a bit tense in the weeks leading up to the event, as some of the clinic staff did not feel that it was appropriate to have such a discussion with the teens. However, after much debate it was acknowledged that this is a critical subject for all teens and that Teen Club is probably they only place they are going to get to have their questions answered in an open, honest and medically correct way.

In preparation for this discussion/forum, teens were notified a month earlier that the June Teen Club would be about sex, giving them enough time and opportunity to prepare questions. The team placed a visible box in the clinic for them to write down anonymous questions about sex and sexual health.

On the day of the event, teens were divided into the usual two groups (13-15 and 16-19 year olds). For the younger teens we had 3 stations: playing games; dispelling myths (as you can see me explaining above); and a short discussion on puberty and importance of abstinence. The teens rotated from station to station every 40 minutes. There was concern that that some might not be mature enough for the topics, but once again they surprised us with their maturity, concentration, and engagement with the subject.

During the short discussion on puberty we taught them about the normal changes that the body goes through, as they get older, the importance of abstinence and the need for protection when abstinence is impossible. We also answered many of the questions they had about sexual issues and puberty. During the myths/facts session the teens were given a myth and asked to go to the area of the courtyard corresponding to their feelings about the myth (true, false, or don’t know). We then discussed the answers in detail, dispelling such myths as “two condoms are better than one” (two condoms are NOT better than one!) and “a girl cannot get pregnant if she has sex standing up” (She CAN!) which are two common myths in Botswana.

The older teens had male and female condom demonstrations led by three wonderful volunteers from the Ministry of Health (MOH), who volunteered their time and expertise on a Saturday. Their experience is extensive – they have conducted demonstrations all over Botswana in many different settings from schools to community centers to other public gatherings.

Teens were divided based on gender, in an effort to encourage more open discussion and stimulate questions. Most were eager to share what they thought to be correct information about condoms and their use. The demonstrations certainly stimulated questions ranging from myths of pregnancy and changes the body goes through during puberty to more complex issues such as age of sexual debut and perceived ideas about the roles of a man and a woman in a relationship.

Then all the older teens were brought together and their questions were answered (both those they had placed in the question box and those which they came up with on the spot). Once encouraged these young men and women were eager to take the opportunity to ask and demystify concepts about sex and sexual health. Due to time constraints we were unable to answer every single question and will definitely have to have more sessions on this topic in the future.

All in all, the event went better than the team expected. The teens were serious and mature about discussing the subject, even more so than many adults when placed in similar situations. We felt their appreciation through their enthusiastic participation, eager concentration, and mature disposition.

At the end of the event, the teens surprised us with a dance number and kind words to say goodbye to me and Gelane as it was our last teen club. We both expressed to them how much we had learned from them and how their strength and resilience are truly an inspiration to all.

Transitions

2011-08-05T18:25:00.000+02:00

Gelane, Bri, Premal and I were super sad to say good bye to each other!
I know we will keep in touch, but after 2 years of living, working, traveling together it was really hard to part.

It has been forever since I posted, I know, but I am going to try to get back into it. You might have noticed that the description of my blog has changed (it is now "tales of my life as a pediatrician in Botswana and beyond....") I figured that was easier than setting up a new blog. That is because I have moved to Cape Town, South Africa! The Pediatric AIDS Corps program had 5 years of funding which ended in July 2011. Other sources of funding were sought and the program transitioned to the Global Health Corps this July. It will be very similar to the PAC program, but smaller and will focus on more than just HIV/AIDS. Though it was quite hard to leave Botswana, all the patients at the clinic there, and the friends I have made in the last 2 years, it was time to move on.

I also had to say good bye to Gizmo our cat. He clearly wanted to come along, but loves to be outdoors and I don't think he would have done well in a Cape Town flat.
Luckily Bilen moved in next door and Gizmo moved in with her.
They are both very happy now ;)

I have taken a job with an organization called South to South. It is an NGO that is funded by USAID and is housed at the University of Stellenbosch in Cape Town. The goal is to help South Africa expand their pediatric HIV program. Many healthcare providers are comfortable treating adults with HIV but not children, so our goal is to help them feel comfortable treating children. In addition, the goal is to increase the number of clinics that provide ARVs (medications to treat HIV) so that patients do not have to travel as far to reach the clinics or wait all day to be seen (do to overcrowding at the centers which exist). You can read more about it here if interested www.sun.ac.za/southtosouth.I am the Pediatric Clinical Advisor which means I will be doing training and mentoring of healthcare workers (nurses, doctors, lay counselors, etc). A lot of my time (about 40%) will be spent traveling around the country. Right now we are focusing on a district called Moretele which is in the Northwest Province of South Africa (about 2 hours north of Johannesburg), more on that in a few weeks after I have actual been.

Almost half of my residency class managed to make it to Sonia's wedding!

Sonia and Elliott are officially married

Before moving to South Africa, I was lucky enough to get to spend almost three weeks back in the States with family and friends. I was really lucky that Sonia decided to get married during that time and so I got to attend her beautiful wedding and see a lot of my friends from residency (as well as two delightful new additions to our St. Chris family - Josie and Walter ;)

Josie, beautiful daughter of Meredith and Trevor

Walter, adorable son of Ruth and Robert

I spent lots of quality time with my parents, grandmother, aunts, uncles, and cousins. Definitely the thing I miss the most about being "this side" is time with family and friends who are "that side" but luckily the technological age (skype, internet phones, etc) helps with that a lot.

I will try to post a few flashbacks of my last months in Bots and then will move on to giving you a sense of life in Cape Town. Right now it is a lot of logistics, finding an apartment, buying a car, opening a bank account, etc but photos and details of all those things to come!

Adventures in April

2011-05-15T21:09:00.000+02:00

The last week in April was an time for another adventure. Josanna, Elizabeth, Bilen, and I drove from Gabs to Rustenberg, spent the night at a cute bed and breakfast and had our customary sushi dinner at the Cape Town Fish Market in Rustenberg. The next morning we drove to Joburg arriving with plenty of time to sort out where to leave my car. We ended up giving the car to Jacob a guy who works for a valet service at the joburg airport. They have a business where they pick up cars at the departure terminal, take care of them (including washing them) and return them to the arrival terminal upon your return. They came highly recommended by the owners of the Bed and Breakfast in Rustenberg. Though I was still pretty skeptical of giving my car to a total stranger in a city known for car theft, it worked out! He drove us from the airport to the bus terminal and was there with the car when we came back and it was cleaner than it has been in a long time! Our bus was 1.5 late so we left Joburg at 11:30 pm and arrived in Maputo at 9:30 am the next day after an uneventful bus ride where we were able to sleep a bit. From Maputo we got a ride to Bilene a beach town about 3.5 hr away.
Bilene was a really tranquil place. Not too touristy. We stayed at a place about a 45 min walk from town which was on the lagoon beach. We spent three days relaxing at the beach, snorkeling with sea horses, and hanging out at a great local bar. Chichunga's became our home away from home. Each day we bought fish from women whose husbands had caught it that morning and Chichunga marinated it during the day and cooked it for us that night. It was the best fish I have ever had (as you can see in the pictures, we did not leave any behind).
After 3 days, we rode back to Maputo and met up with Gelane (who had been to Cape Town with plans to run the 1/2 marathon - though those plans were thwarted by shin splints she still had a good time there). Maputo is a much busier city than Gabs, and a lot dirtier. We took tuc tucs around the city, explored an old fort, ate at the fish market, and did a fair amount of shopping. At night we found a great bar/club which had live karaoke and the following night a reggae band. We had a minor run in with the police since we were not carrying our passports on our way to a club! They pulled us over during a random stop (when we happened to have 6 people (including the driver) in a cab which is apparently not allowed, though many more unsafe modes of transport seem to be just fine) and told us that we were supposed to have our passports with us at all times. After much hemming and hawing (I think they were just looking for us to bribe them), they finally agreed to accompany us back to the backpackers where we were staying so we could show them our passports and then they left us alone. There were also several run ins with giant rats everywhere we went, not the best when you are eating!
After another overnight bus ride back to Joburg we drove to the Drakensberg mountains (a mountain range on the border of South Africa and Lesotho). It was gorgeous. We stayed at a great backpackers where there happened to be the "Smoking Dragon's Women's Music Festival"that weekend. 48 hours of music from woman performers. It was great fun though we will have to go back to actually explore the Drakensberg since we didn't get to do any hiking.
Here is the trip in pictures: )

Training, Passover, and Tutoring

2011-05-05T22:59:00.000+02:00

The very appropriate coaster that was on the presenters' table during our training.

The first week of April I was back to Bloemfontein, South Africa to do another training. This time it was an Advanced Pediatric HIV Training. Many of the nurses and doctors who attended had been at the basic training in February. It was quite a challenge to explain concepts of antiviral drugs developing resistance to a group of mostly nurses who do not really have the background to understand it (resistance is a very complex topic even for specialists). But we managed to make it a bit fun by having the participants act out the parts of virus and drugs to visually demonstrate. Nevertheless many of the participants got to catch up on their sleep during the training, though we got a lot of positive feedback at the end and people did do better on the post test than they had on the pretest.

After a week in Bloemfontein, I returned to Botswana and got to celebrate another passover in Botswana. This time Liz and Jon hosted a seder. We could not find any matzoh this year (though there was some last year, I am not sure what happened). So Liz actually made her own matzoh!! And then she even crushed it up to make matzoh meal and matzoh balls which were darn good!

Jon was a very entertaining seder leader

Gelane throughly enjoyed her first seder and first matzoh balls!

We had a lot of vegetarian dishes and I made a really good flourless chocolate cake (thanks to Mom for bringing me Scharfenberger chocolate which totally made it).

We even had Leonard (one of the Infectious Disease doctor's almost 2 year old son) to find the afikomen. (He lost his pants during an accidentally spillage earlier in the evening and was more interested in the wire bowl he found than in bargaining for something in return for the afikomen ;) It was great to be able to celebrate with friends, though I did miss the crazy Scherzer/Reisman seders!

During April I also did a lot of tutoring (I was trying to teach multiplication to K.N. above). We started a tutoring program for patients in our clinic as many of them are doing poorly in school (a combination of being sick a lot, missing school frequently for routine doctors visits, and developmental delay can happen from HIV itself - especially for those patients who were started on treatment later in life.) We have recruited volunteer tutors from University of Botswana, among other places, and are now able to offer tutoring every day and on Saturdays. I spent a few Saturdays in April trying to remember how to do calculus, explaining long division, and learning the capitals of African countries.

Yoga, Jazz, and Family

2011-04-20T23:12:00.001+02:00

The gorgeous coast along the Garden Route

The kids who guided us to the elusive eye

The last 2 weeks of March were quite “busy” with vacation. It started with a weekend yoga retreat. I have luckily been able to continue my yoga practice here in Botswana, actually going a lot more than I did in the States. I have a great local teacher and the classes are smaller so there is a lot of personal attention. My yoga teacher’s teacher did the yoga retreat. It was held in Groot Marico, which is a small town in South Africa about 2 hours from here. The setting was ideal, a small retreat center in the middle of nowhere with no cell phone reception, delicious vegetarian meals and nice cottages. Yoga was conducted in an octagon shaped building and as our faces were inches from the ground she mentioned that the floor was made of a cow dung/mud mixture! Wish I hadn’t known that part of it, but it did not smell and was coated with some kind of oil to keep it together….The theme of the weekend was "the elements," which meant exploring the parts of us that are Earth, Fire, Water, Air and Space. I was only around for the first 3 elements since the retreat was three days and we only attended for two. Exploring the element of Earth meant collecting piles of dirt and staring at it for 15 mins, then spreading the dirt out and staring at it again for 15 min and then putting it back in a pile and seeing how we felt about it now that it was back in pile. We then discussed how everyone felt about the dirt and what the earth element meant to us. While I found the idea of the elements interesting and attempting to try to balance them in each of us is a very important and noble goal, staring at dirt, moving water, still water, candles, fire, etc took a lot of patience on my part, which was also a good exercise ;) The yoga was great, again it was a small group so we got a lot of personal attention. We also took a trip to "The Eye" a crystal clear spring near the retreat place, it was quite an adventure to find as it is tucked into the brush along a dirt road (luckily we ran into those children above who pointed us in the right direction). It was raining and cold, but that did not stop us from zip-lining and jumping into the nice cold water ;)

On Sunday I left the retreat by way of a packed combi (minivans used for public transport around South Africa) to travel to Johannesburg and meet my parents who had arrived a few days earlier. The following day we flew to George along the Southern coast of South Africa, rented a car and began to drive the Garden Route.

The Garden Route is the stretch of coastline between Port Elizabeth and Cape Town. It is a gorgeous drive filled with amazing mountain passes, beautiful beaches, and lots of good fish dinners (something I never get in Botswana)! We spent the first two nights at an amazing B+B in Plettenberg Bay. The owner was an amazing cook and the location was amazing. While there we went to the Tsitsikama National Park and hiked to Storm's River Mouth and part of the way to the waterfall. I even convinced my dad to go zip-lining!

On the bridge at the Storms River Mouth

Along the way to the waterfall (we did not have time for the whole hike but the views were breathtaking)

We then drove on Route 62 which is the part of road that weaves in a out of the mountains on some amazing passes. We spent one night at a lodge in the town of Oudtshoorn that was on an ostrich farm and even collected a few ostrich feathers.

Eric the Farmer

Between Oudtshoorn and Swellendam was the famous Ronnie's Sex Shop. It is a bar/restaurant in literally the middle of nowhere that started as a joke and has now becoming a famous stop along the route. Had to get the classic photo of Dad on the disintegrating tractor in front.

A photo opportunity in one of the mountain pass

We arrived in Cape Town on Friday in time for the Cape Town International Jazz Festival which just so happened to be the weekend my parents decided to visit (what great timing). We saw some amazing performances, among them: Hugh Masekela, Earth Wind and Fire and even my friend Matt who was playing with Citie a guitar player from Botswana (the first Botswana artist to perform at the Jazz Festival).

Hugh Masekela (sorry no matter what I do this picture won't rotate, so you will just have to turn your head ;)

Citie on guitar and Matt on sax

We spent four full days in Cape Town exploring. From taking the cable car up Table Mountain to listening to a concert in The Botanical Gardens to eating amazing food it was an awesome time in a great city.

Dad smelling the flowers at the section of the Botanical Gardens designed for blind people (all the plants had powerful smells and signs about them were translated into Braille as well.)

The Philharmonic performed to a packed crowd of serious picnickers (these people were really hard core about the picnicking right down to the stakes which held wine glasses!)

My parents and their friends Richard and Bobbie Polton (who joined us in Cape Town) and were able to find some nice recycled art of their own with the master artists

Mom with a lion made of wire and beads at the Streetwires store (a place that has hired some the local artists who make all kinds of objects out of recycled cans, wires, beads, etc). We purchased quite a number of recycled designs from local artists at a art fair we happened upon as you can see above.

He looks like a professional, eh?
There are tons more pictures and stories, but I wanted to get this up before the next adventure (which starts tomorrow ;) Happy Passover and Easter to all (stories from this year's passover to follow ;)

March

2011-03-13T22:28:00.000+02:00

Wow has it really been a month since my last post? Yikes time is flying....
Well the end of February brought another excellent teen club. We started the day off with two inspirational speakers, one is a judge in Botswana (one of the first female judges) and the other a radio DJ. Interesting combination, but they both talked about leadership and what makes a good leader. Both had great messages about having good self esetem and the confindence you can do things because you can't be a good leader without beliving in yourself first. The teens were very responsive to the messages and asked some good questions. Then we took the older teens (16-19 years) to the pool. Seeing as Botswana is a land locked country that is largely a desert, there are very few opportunities for the kids to learn to swim. Only about half were interested in trying (all in the shallow pool at the Univeristy of Botswana) and the other half played group games with water balloons. It was a lot of fun and since it was really hot outside, everyone was happy to get wet!

Bloemfontein from the air

The first week in March I went to Bloemfontein, South Africa to conduct a basic Pediatric HIV training. There were 31 health professionals at the training, mostly nurses, from all over the Free State (one of the provinces in South Africa which Bloemfontein is the capital of). We taught them about pediatric HIV management. Many are already taking care of HIV positive patients but some of the nuances of managing children with HIV (like disclosing their status to them) were new to them. The training was a week long and well received. There was not much to do in Bloemfontein during the hours we were not conducting the training so I spent a lot of time at the "waterfront" mall. The water is a man-made pond with a water fountain (or "water mountain" as my boss's 2 year old son calls it) in it, but at least there were some decent restaurants.

The "water mountain" at Waterfront Mall

Last week I was back in Gaborone working at the clinic. On Tuesday night we celebrated International Women's Day by attending an event to raise money for an organization set up to fight abuse against women. Unfortunately most of the speakers were not very motivating, just talked about themselves. But there were a few performances including one by Shanti-Lo (a stunningly talented transgender singer) who is becoming very popular in Botswana despite the country's conservative nature. Hopefully the fact that they chose him to be the closing act is a sign of the possibility that there is improving equality and openness in the society as a whole, slowly but still....

The Elusive Black Rhino

2011-02-13T21:40:00.000+02:00

Last weekend we decided to go to the Khama Rhino Sanctuary for the weekend. I have been there many times since it is in Serowe (where I used to live), but I had never spent the night. A group of 12 went up and we stayed at the wonderful chalets that they have. There was also a great tree for tree climbing (as you can see above ;)

A really pretty ?grasshopper and a Daddy ostrich with babies

We went on a game drive on Saturday afternoon and saw plenty of wildlife. We told our guide that we really wanted to see a black rhino since none of us had ever seen one. In the sanctuary there are 35 white rhinos and only 3 black ones. The black rhinos are also harder to spot as they eat from bushes so stay in the dense parts of the park while the white rhinos are grazers eating grasses in the more open areas. He was on the look-out and managed to find many other things, but no black rhinos.

A lilac breasted roller in flight.
They have the colors of the Botswana flag under their wings, something I never noticed before

We even saw one of the oldest rhinos in the park. Apparently, you can tell by the length and the straightness of their horns - the longer and straighter the horn the older the rhino. Above is a mama and her baby. After 2 hours we returned to our chalets and began to prepare for the brai (South African way of saying barbecue). I wanted to make roasted potatoes, but realized we had forgotten to bring oil. So I headed to the restaurant (a few hundred meters from our chalets) to see if we could borrow some. They were nice enough to let me have a small cup of oil and I started to head back to the brai. As I stepped out of the restaurant I saw a black rhino staring at me! I shouted to the others to bring the cameras and watched as the rhino tapped on the edge of the pool which was covered. He was rescued as a baby, so is more used to humans than the other rhinos in the park and has grown accustomed to drinking from the pool outside the restaurant. One of the park staff members came to remove a section of the pool covering for him and we watched as he stuck his head in the pool and drank.

I offered him some oil as well, but he was not interested ;) After he finished drinking he began to walk towards us so we scattered.

We followed behind him for a bit and at one point he turned around looked at us and then sprayed the area around him to mark his territory. It was quite entertaining.

We returned to our brai and had a great feast which included a nice fire on which to roast s'mores!

Long Time

2011-02-11T16:36:00.000+02:00

Celebrating my birthday with karaoke night and great friends

Has it really been more than 2 months since I have written a blog post? Wow time is flying! At the end of November I went back to the States since my mother was having her foot reconstructed (after 6 weeks on crutches she is now happy to have one foot free of bunions and neuromas), celebrate my birthday, and Thanksgiving. It was great to see family and friends and stock up on some of my favorite supplies (M+Ms, esp the mint ones, peppermint patties and black beans ;)

In Khami Ruins, near Bulawayo, Zimbabwe.

One of the few remaining walls at Khami Ruins. The royal family apparently lived on elevated rock walls on top of the hill (anything they could do to make themselves appear better than the common folk....)

The month of December flew by with a trip to Bulawayo, Zimbabwe over Christmas to see a beautiful national park, rock paintings, and ruins of an ancient civilization (Khami Ruins). I celebrated New Year's Eve weekend in Cape Town which was a lot of fun as it is one of the most beautiful cities ever!

New Year's Eve in Cape Town! (thanks to Alexis for picking out the perfect shirt ;)

I feel like I wrote about these trips since all the pictures are on facebook, but I guess I never did.
I still cannot believe that January is over, it feels like the new year started yesterday.
I have also been doing some work ;) I am still learning a lot from my patients. Here are a few interesting stories.
B.C. is a 17 yr old who is doing really well on his HIV medications. He always has good adherence, his virus is suppressed and he was a seemingly uncomplicated patient. When I saw him at the end of December he said he had no issues, his physical exam was normal and his blood work looked good. We talked about school (he is in Form 5, which is the last year here) and he said it was going okay, but that he wasn't doing as well as he wanted to be doing. He has been getting Bs (which is considered excellent here, esp at our clinic where most patients are getting Ds or Cs). I told him about the tutoring program which we recently started to help kids with their school work since many of them are doing poorly and spend a lot of time at the clinic waiting for the doctors, medications, etc. He was excited and we agreed that he would meet the volunteers coordinating the program that day. As I was printing out his note he said "you know I actually have been feeling kind of empty recently." I turned around. "What has been going on?" It then came out that he has been feeling depressed, has tried to commit suicide (he tried to drown himself in the bath tub) and is having a terrible relationship with his older brother who is his primary caregiver. After several hours of discussion, involving our clinic psychologist, calling his aunt who came in (when I called her at work she dropped everything and came right away - she had sensed something was different, but did not know what to do and he had not told her anything), we worked out a safety plan. He said he was feeling a bit better having told people and both he and his aunt felt that he could be safe at home. He came back the following week and was feeling better having spent the Christmas holidays with his family in the north of Botswana. He is now coming several times a week for tutoring, has brightened-up considerably, and has really formed bonds with the volunteer tutors.

I also got some sad news. B.R. the very sick 10 month old whose house I went to back in Jan (see "Inreach" Jan 29) and who a few months later went missing has died. We tried our best to track down the family last year, getting the local social worker and even the police involved, but we were unsuccessful. This week our in-reach team was finally successful in contacting the mother's boyfriend who told them that the child had died. We do not know what happened and still have not been able to contact the mother (according to her old boyfriend she does not have a cell phone) and get her care. It is incredibly sad to know that B.R. most likely would have been fine had she been able to get her medications. But unfortunately medications only work if you take them and sometimes there is no way to get that to happen.

Other times we are more successful. P.S. is a 6 yr old who was admitted to the wards in January with severe pneumonia and Tuberculosis. At an outside hospital they asked the family for permission to test for HIV and the parents declined. However, since it was medically necessary to know, the hospital sent the test anyway and it came back positive. The child was very sick so she was transferred to Gaborone. When she arrived the team disclosed the positive diagnosis to the parents (it had not been disclosed at the outside hospital) and the parents were quite upset with the fact that the child had been tested despite their objections. The reasoning was explained to them, but they refused to believe the diagnosis and refused to have her retested. The ward team spent a lot of time with the family and the child recovered from her acute illness but they were still unable to convince them of the HIV positive status and need for treatment. So they sent the family to our clinic for further counseling.
The nurse manager and I spent 2 hours trying to explain things to the parents, get them to consent to re-testing (so they could believe the diagnosis) and get them to test themselves. The father (and culturally he spoke for the mother who refused to make any decisions without him) was adamant that no tests be done and wanted to have the opportunity to take the child to a church in South Africa to pray for her. He is a primary school teacher and did have a basic understanding of HIV and said that he did not believe that praying could cure HIV, but he wanted the opportunity to pray for his sick child. After much discussion and talking with the wards team it was agreed that the family would take the child to South Africa for the weekend and then return to the wards to have further discussion. When the family did not return to the clinic as expected the following Monday we called the father who said he was still not ready to have the child tested. However, he eventually did bring the child back to the wards that night. Further discussion reveled that he thought that I (and the rest of the doctors) were on a mission to prove that his child was positive for research purposes (though we had never mentioned research of any kind). So our social worker (whom he had not met and did not associate with the clinic) spent 5 hours with the family trying to come up with a solution. At that time we had gotten the child's CD4 count back and it was 20 (showing that she was incredibly immune suppressed and needed to start treatment ASAP). As this issue was quite urgent, they told the father that they might have to involve the police and what little child protective services there are here if he did not agree that the child needed treatment. At that point the father took the child and the mother and stormed out of the hospital. We were all worried that we had lost them and were planning to contact the police to try to find them. However 24 hours later, the family returned. The father had taken them all to a local testing center and they had all been tested and came back positive. He brought the results to the hospital ward and apologized to the ward team for not believing them. The next day we started the child on medications and the parents will go to have their CD4 count check to see if they need to start as well. It has only been a week, but so far it seems that the family is giving the medications well and we remain hopefully that things will continue to go well.

So things are not always what they seem. Sometimes the "stable" patients are actually the ones who need the most help and the ones who you think will never see the light eventually come around. Of course, there are also the times, as in the case of B.R., when despite all of our best efforts we cannot reach an acceptable arrangement. And I have also re-learned that sometimes patients just need time to come around and feel in control of the situation. And of course gained even more appreciation for the importance of a team approach.

Soweto Marathon

2010-11-15T00:12:00.004+02:00


Botswana group plus Duncan on far left (Baylor PAC doc in Swaziland)					.	Duncan, Bri, Premal, Matt, me, Amit, Gelane, Philip

November 7th was the Soweto Marathon. There was no way I was even thinking about running a marathon, but who would give up the chance to do a 10 km walk through one of the most famous and culturally important neighborhoods in the world?
We drove down to Joburg on Friday after work, arriving later than we had hoped. We were staying at a bed and breakfast in Soweto. Unfortunately there are two streets with the same name in Soweto, only one of the streets housed our B+B the other was in a rather dodgy part of Soweto and was the one the GPS chose to take us to, oops. Luckily the people who owned the bed and breakfast were extremely helpful and sent their son out to meet us and show us the way. Gotta love small family owned operations. The B+B was great. There were only 4 rooms and each had a lot of character

Here we are in front of the B+B

On Saturday we spent the day exploring Soweto. We started with a game of football with some of the children in the neighborhood.

Then we walked down Vilakazi Street (where Nelson Mandela, Desmond Tutu and other famous people lived). We made our way to the Hector Peterson Museum. Hector Peterson was a 13 yr old boy who was killed by police on July 16, 1976 during a youth march protesting the use of Afrikaans as the medium of instruction in South African schools. The museum was a tribute to him and all the others who died in the struggle. It was well done with lots of photos, descriptions of the events, and videos. Amazing to imagine 13 yr olds fighting and dying for a cause when many of today's 13 years can think of nothing but TV and play station.


The fountain outside the museum (no photography allowed inside). The picture is of one of the older youth carrying Hector with his sister walking alongside screaming.

After lunch on Vilakazi Street we headed to the University of Joburg where there was a Barista Competition. Baristas (coffee makers) from all over the city were competing to see who was the best one. I never knew there was so much technique involved. Each barista had to make 4 espressos, 4 cappuccinos and 4 of a speciality drink, which they invented, in 15 mins while judges watched their every move. They were even judged on whether the coffee that was pressed into the machine was completely level...It was kind of crazy but we got to drink some really good cappuccinos (unfortunately the drinks made by the baristas in the actual competition were only for the judges).

We had dinner at Wandie's Place (a famous restaurant in Soweto). Not my favorite food as it was traditional South African buffet, but there was really not much for vegetarians (though the butternut squash was really good ;) Went to bed early since we had to be up at 5 am for the race which started at 6:30 am! The race left from soccer stadium (one of the new stadiums built for the World Cup) and the route was through Soweto which involved some rather large hills! There were over 11,000 people participating (about 5,000 in the marathon and the rest either walking or running the 10 km).

Walking to the start did not count as part of the 10 km ;)


The walk started 10 min after the run so we got to see the winners of the 10 km run coming back. Here they were passing the 8 km mark after only 20 min! And many (as you can see here) were running barefoot!!!

Here we are going up one of the longest hills. It was seriously 1.5 km of straight uphill!

Around the 9 km mark and still going strong!

We finished in 1 hr on 35 min (I know it says 1:45 but the walk started 10 min after the run and the timer was for all of the 10 km ;)

The winner of the marathon finished in 2 hrs and 20 min!!!! He ran 42 KM (26 miles) in 2 hours and 20 min and ran across the finish line like he had just gone for a little jog! He was from Lesotho where there are also a lot of hills!

After the race, in our matching race shirts, trying to capture a jump shot

IN case you want to see more photos here is a slideshow of many more....

New Diagnosis

2010-10-28T21:47:00.000+02:00

Most days in clinic I see patients who are on anti-retroviral medications (ARVs) and are doing excellently. Today for some reason was different. Amidst the routine check-ups and failing teenagers I saw three children who were newly diagnosed. Luckily the number of newly diagnosed children is decreasing all the time in Botswana, so I can often go for a whole week without seeing one. Anyway I thought I would share their stories (I've changed their names).

Mpho is a 12 yr old boy who looked to be about 8. He came to clinic with his older sister. He has been sick on and off for many years now, but never sick enough to get admitted to the hospital. Recently he has had persistent diarrhea (often a sign of HIV infection and something that qualifies him to start on ARVs without even waiting for his CD4 count). His mother has also recently become sick and so his older sisters decided that both he and his mother should be tested. They both tested positive last week. His mother will get started on medications at the local clinic near where they live, but his sister wanted him to be seen at the children's center, so she brought him in. He was quite shy and did not really know why he was there. When I began to tell him about the bad guy in his body that was attacking his soldiers he said he knew that they bad guy was HIV. I asked what he knew about HIV and he said "there is no cure." "That is true, but there are very powerful treatments and with those medications you can live a long and healthy life and be anything you want to be!" He smiled a bit. We sent his baseline blood work, started him on prophylaxis against opportunistic infections, and had long discussion about the importance of adherence and who will help him with his medications. He will return next week to start ARVs.

Nametso is a 7 yr old who came with her mother and her baby sister. She is severely wasted with almost no fat on her body. Her mother is on ARVs already, but for some reason no one ever thought to test Nametso until today. For the last few weeks she has been coughing (occasionally blood tinged), has had fever on and off, and has night sweats (all signs of likely TB infection). Today her mother brought her to be tested and our rapid tests confirmed our suspicions that she is in fact positive. Luckily her baby sister is negative (she was born while the mother was on treatment). Cases like hers really make you realize the importance of asking about all family members and if they know their status. I try always to ask about siblings, parents, etc of the patients I am seeing and we stress the importance of this in the trainings we do, but it it is easy to forget in the course of a busy clinic day. Before we can start her on ARVs, we need to figure out if she has TB. She had signs of pneumonia on examination and I would have liked to get a chest x-ray, but the machine at the hospital has been broken for the last 2 weeks. So I treated her for bacterial pneumonia and arranged for her to get a sputum induction tomorrow (since children are often unable to cough up mucus we have a procedure to help them do that). Unless she gets dramatically better on the standard antibiotics, we will likely empirically start her on TB treatment since it is a hard diagnosis to make in children. And then she too will be started on ARVs.

Then there was Precious. She is 8 months old and was born to an HIV positive mother who actually got the Prevention of Mother to Child Transmission package. However even with the current prevention measures in Botswana, there is still a 4% chance of transmission (<1% in developed countries where women are started on full ARV therapy, given C-sections, and formula feed their babies). She seems to be one of the unlucky 4%. She came today with severe oral thrush. The thrush is so bad that she has not been eating or drinking well and was moderately dehydrated. For the last 4 months she has not gained any weight. She looked severely wasted, dehydrated, and pale (likely also has anemia). One look at her and I knew she had to be admitted. She was tested for HIV back in March (as per the guidelines babies born to HIV positive mothers should be tested around 2 months of age), but the results were never returned. No one told her mother to bring her back for repeat testing (despite the fact that she has not gained weight in 4 months which is often a sign of HIV infection in children) and it wasn't until she got sick that she was brought for repeat testing. With babies we have to do PCR testing which takes at least 2 weeks to get results, but looking at the baby I am pretty sure she will be positive. I walked her over to the pediatric medical ward and discussed the case with the medical officer. He placed an IV, drew blood, and admitted her to begin to rehydrate and stabilize her. We will find out her status for sure in 2 weeks and she will be started on treatment then (assuming it is in fact positive).

Another interesting case of today was Thato. He is 15 and came to clinic with his mother. They were both diagnosed in 2004 and neither has been started on treatment yet. They are both clinically doing well (some patients are able to ward off HIV for a long time before becoming sick). We have been monitoring his CD4 count and it has been steadily dropping over the last year (a sign that he needs to start ARVs soon). However, he and his mother are not ready to start. His mother has found some molasses which is supposed to boost the immune system and they have both started to take that. They are both pretty knowledgeable about HIV and understand that molasses is not a cure for HIV and that the only treatment for HIV is ARVs. His father is actually already on ARVs and doing really well. However, they feel that before starting a life-long therapy all other options should be tried and she wants to see if the molasses will work to boost the immune system and prolong the period of time before which medications have to be started. When I pointed out that the CD4 count was dropping despite the molasses she told me that was because she had not been able to afford the molasses for all of the last year, but that over the last month they were consistently taking it. We agreed to repeat the CD4 in a few weeks and if it is less than 250 (the cutoff in Botswana, though the World Health Organization now recommends 350 and in developed countries it is recommended that patients start way sooner,) he will start ARVs and if it remains high we will continue to wait.

It was a rough day, but luckily they aren't all like this!