Botswana vs. Tanzania rugby match

When we got back, we were super tired. But we didn’t really have time to rest – we went almost immediately with the rest of the group to a rugby game! I’d never been to a rugby game before, and it was pretty big. It was Botswana vs. Tanzania, and they were playing in one of the two grass stadiums in Botswana (both are in Gaborone). Botswana trounced Tanzania – it was so much fun! They played some awesome music and the crowd was great. There were these teenage girls sitting a few rows in back of us that were so funny… they kept doing these great cheers and were so into the game! It was hard to not get involved, and I was totally rooting for Botswana. When they played the techno-ish music, all of us were dancing in the stands with the crowd. I definitely missed Pete during some of the dancing. They kept on playing this really really good song called “Stand up.” Apparently, it’s by Right Said Fred! Who even knew he was still around? I need to download it. And it’s funny – in the states, the bar closes before the stadium closes, I guess so people don’t drive home drunk. Here, the bar stays open way after the game ends. Most people aren’t driving anyways, I guess, but the definitely make more money that way.

It was cool seeing a rugby game and learning about it too. There are these funny things called scrums… where the two teams basically have a shoving match against each other as a team. It’s sort of like a jump ball in basketball. Whoever gets to the ball in the middle first throws it to someone on their team on the outside. And the scoring is a little tricky, but it’s basically like football in that you have to run it into an endzone. The only passing that is allowed is lateral or behind you, otherwise it’s an off sides call. And when you run into the endzone, it doesn’t count as a score until you touch the ball to the ground. And where you touch the ball to the ground is the point at which you line up at to kick the extra point, so many players try to get to the middle as much as they can before touching the ground. I’m sure I’m butchering the rules, but it was pretty fun to learn.

We also met quite a few people there – they seem to enjoy meeting foreigners, and I think some of them don’t know quite what to make of me, a Chinese woman. Two guys we met were Tanzania fans, and they were so funny. Every time Botswana scored, they ordered another beer, and were like, maybe this will make it better. And after the next score, nope not any better! They're the two guys in striped shirts in the picture. It turned out that one of the guys owns Primi’s (the place we went to dinner two nights ago). Their names were Ronald and something I couldn’t quite make out – it sounded like Adam. They invited us out for drinks at Primi’s, so a few of us went there for dinner after the rugby game. Even Steve Gluckman and Barry Nathans went! It was a ton of fun, and they ordered us so many different shots, especially me at first. But I was getting sick and by the end, I had stopped drinking and was ready to go. It was nice to meet some other people though… they invited us out for other things later, like fishing or going out to other clubs! I don’t think we’ll keep in touch with them that much, but it’s nice to know we have other options. Here are a few more pictures of us and the people we met:

Ronald took this nice picture of Kiona, Kristy and I.

This is Kiona, Thabo, Josh and Lisa.

From top left: Dr. Steve Gluckman (who started the whole Penn in Botswana program), Dr. Barry Nathans (pediatrician), Kristy (med student), Kiona (med student), Lisa (resident), Mike (resident), and Josh (recent Penn grad)

Yummy Pies!!

Nothing much else happened today – I was on call, but there weren’t that manyt admissions. I was actually a little bored. I had to stay until 9pm, and I only admitted 2 new patients. And I missed Quizzo with everyone else (except Lisa and Phil, who were also on call) at the Bull & Bush. I actually did try to make it, because we got out right at 9pm, and Quizzo didn’t end until about 10pm. The night transport people at the hospital (which we use when it’s too dark to walk home) actually said that they would drive me there. But then we got on the road, and apparently a big football (soccer) game between Botswana and some other country – which is a big deal – had just ended and there was a ton of traffic! The driver was no longer willing to take me to the Bull & Bush, but even if he had been willing, it probably would have taken him half an hour to get me there, and then I would only have stayed for half an hour. So it wasn’t really worth it. We’ll make it to the Bull & Bush eventually – it’s a big place for ex-pats and foreigners to hang out.

I did go to have lunch at the main mall with a bunch of people. We all went to Pie City, which sells all these different handheld pot pies. I had a chicken peri peri pie. Peri peri is their version of a hot sauce, and the pie was pretty spicy! But it was really good, and it’s pretty inexpensive – the pie, plus a drink ran less than P10. I will definitely be coming back for more pies. Although I may try the competing pie place next time – it’s called Pie Time. I think that’s sorta funny.

It was also pretty cool because I talked with Betsy a lot today – she’s getting an anthropology PhD from University of Chicago. I believe she’s on a Fulbright scholarship, and knows Setswana relatively well. So I had her teach me a bunch of stuff. We also had some good discussion about the health system in Botswana, and the different organizations, both international and home governmental, that provide health care, medications, and supplies. If I have time, I’ll definitely write more about it later, because it’s pretty interesting.

The Riverwalk Mall

Nothing too crazy happened at the hospital – I did two LP’s and a blood draw. Got both LP’s, the first one was after a few tries. This patient is a 30 year-old with HIV and altered mental status and we have no idea what’s wrong with him. The head CT was normal, so we decided to do an LP (lumbar puncture), but he’s out of it, so he kept moving and it was pretty hard to get. Even Boipelo tried and she couldn’t do it, and then I tried one more time and finally got it – it was a very traumatic (bloody) tap, but at least I got some CSF. I’m sure it’s a matter of being obstinate, but I’m still pretty proud that Boipelo couldn’t do it and I got it. The other guy was someone that needs to be tapped every day. This week, sometimes Boipelo has done it, and sometimes I do it – he likes me better. The first time I ever tried it (on Tuesday), I hit it on the first try, and Boipelo apparently took a bunch of tries on Wednesday. And today, I sorta had a first try, but I didn’t put the needle very far in. And the 2^nd time, I got it easily. So he says he likes it when I do it. But I don’t know how long I can keep it up. I guess we’ll see – I have to keep doing it until his intracranial pressure (the LP opening pressure) goes down. And this was the first day that it was lower than the day before, so I hope that this means he’s getting better – he has Crytococcal meningitis. We may have to put in some sort of shunt because we can’t keep tapping him every day. Boipelo says to not get my hopes up about him because she has seen pressures that got lower, then went back up the next day, but I don’t care! I’m getting my hopes up! He’s on Amphotericin right now, which is an awful drug. We have to give him 4L IV fluids (IVFs) every day because this drug seriously dehydrates you.

And tonight, we finally got out a little earlier! Like 6pm! It’s the earliest so far. This is my and Phil’s easy week – only on call Monday and that’s it. Our teams are on call Saturday but as Penn students we don’t have to come in on weekends. Next week will be super hard though. We pick up all the patients on Monday that our teams admitted over the weekend, and then we’re on call Wednesday and Friday.

Anyways, so because we got out early, we all went to the Riverwalk Mall (one of 3 malls in Gabs) and there’s a big grocery store there! Sort of like an American supermarket! And the mall is indoors, and has clothes shops, a food court, something like a Walmart – very similar to an American mall but with Botswana flavor. So I bought some groceries, and then we went to the Italian restaurant there called Primi’s. There were a lot of Americans there – apparently it’s a very nice restaurant by Botswana standards. I got a big pasta entrée (more than enough to take home) and a glass of wine for like P80, or $14. Not too shabby.

Dinner with the big wigs

So intake this morning was a little surprising – my team had 3 patients die over the weekend – one 77 year-old with metastatic adenocarcinoma, which wasn’t too surprising. But the other two were young, 30 and 42, with mental status changes, that I thought were going to live! It was a little difficult to take – I was not expecting it, and I had poured so much work into them to try and make them better. Some of these patients you know are going to die, so it’s not worth 3 hours of your time to try and diagnose or treat them. But these two I thought were going to make it. I guess that’s the way it is here… Nothing much happened today though. I thought we might pick up a huge number of patients since Boipelo was on call Saturday, but we only picked up 3 or 4.

Tonight we went out for dinner again, this time at Tendani’s house – she used to be an MO, and was leaps and bounds better than the other MO’s, so got recruited to run IDCC, which is the Infection Disease Clinic at Princess Marina Hospital – it mostly takes care of patients with HIV and AIDS. However, she is rarely ever there anymore as she now is very involved in PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief). Her dad is the Minister of Finance in Botswana, arguably the 3^rd most important person in Botswana, so she comes from what seems like a line of administrators. Interestingly, her husband is an artist, and seemed to be a very cool guy – although I didn’t really get to talk to him.

There were some very interesting people at the dinner. The entire Penn team had been invited, and she had invited a lot of PEPFAR people as well. I had very interesting conversations with a few different people – one was the son of a prior president and he told us a lot of stuff about Botswana politics. I met a few PEPFAR people too, and they explained to me what PEPFAR does – it helps set up HIV/AIDS clinics in small towns in Botswana so that eventually, hopefully all citizens will be able to receive treatment. HIV is such a huge problem here – I would say that 75% of my patients come in knowing they are HIV positive. And who knows how many of the other 25% are HIV positive. We offer the testing to everyone, but not everybody wants it. Boipelo says it’s because most of them are in denial or are afraid, but they have really good accessible treatment now, so it’s starting to become a little more openly talked about.

Food and Jazz

It was a day to eat! We went to this place called Sanitas for brunch, which does pretty well in providing good American-style brunches. It’s actually a tea garden and horticultural center, where you can buy lots of different plants and gardening supplies. In the winter, Botswana is very dry and brown, so the lushness and greenness of this place is a welcome change, although it probably requires ridiculous amounts of water to keep it that way. At any rate, after eating, it was fun to stroll around and look at all the different things in this large outdoor store. And we also got gelato from their counter, even though we stuffed ourselves during brunch. :)

During the day I tossed a Frisbee around with Amy and Phil. Amy actually was quite good – she said she used to throw a Frisbee in summer camp. It was pretty fun until one of us threw it into the bushes near our apartments. All the bushes have these super sharp thorns, and two of them actually pierced the Frisbee! We used pliers and still couldn’t get them out! Eventually we were able to cut off the ends and file them down so there was no longer any protrusion from the Frisbee, but the little bits of wood were still embedded in the Frisbee. Crazy.

Then for dinner, a few of us went out for Ethiopian food. It was this place located at the Riverwalk mall that Dr. Gluckman recommended to us. They had a buffet which consisted of chicken with egg, beef, lentils, some other vegetable, and of course, plenty of that spongy bread, injera. Unfortunately I wasn’t very impressed – I think I like the Ethiopian food in West Philly better! It wasn’t as spicy as I’m used to it being, and the bread wasn’t sour like it normally is! I think the Ethiopian food in West Philly is actually more authentic, since there are a ton of Ethiopians in that area. I’m willing to bet that the Ethiopian food here has been tamed down a bit for the Motswana.

After dinner, a few of us (Lisa, Amy, Joanne and I) went and joined Kristy, Kiona and Phil at Botswana Craft for a jazz concert. The band playing was called Punah, and I guess they are known to quite a lot of people, but are not really super famous. It was a ton of fun – after a while, we joined in the dancing with the locals who whole-heartedly welcomed us. There was dancing in groups (like in the states), dancing in a circle (I think there were specific steps to this, but we certainly didn’t know them), and dancing in sync with specific movements, like the Macarena (which I could sorta do after watching and miming the other dancers for a while). Most of the dancers ranged from 20-40 years old, with the young men being pretty entertaining to watch. However, there were these two old men (probably in their 60s) dancing and they were hilarious! Their moves were very… original. One of them had very jerky and deliberate movements, like those men in the parks painted in silver who pretend to be statues and move robotically when you put money in their can. Joanne took some video, and I’ve got to get a copy of it. :)

The band Punah was also very good – I definitely enjoyed their music. Kristy bought their new CD and unfortunately it came damaged, but I burned what I could onto my computer. Funnily enough, several days later I was walking through the Main Mall, where there are tons of street vendors out at lunchtime, including ones that cell CDs and DVDs. I heard music being pumped out from one tent, and I said, “that’s Punah!” and the vendor was surprised and said, “Yeah, that’s Punah!” And he asked if I wanted to buy it but I said I already had it. Even though it wasn’t a huge crowd that night at the jazz concert, I guess their music is relatively well-known.

The second day at Tau

We got a wakeup call at 6:30 am today for our second early morning game drive. The first thing we saw were these little vervet monkeys sitting right on our roof! They were pretty cute. During our gram drive, we spent most of the first part of the morning chasing after the mother lion and her 5 cubs, but it was so cold she probably had them hidden away. I was glad I brought all these warm clothes – it was pretty windy and chilly. Some of the other people didn’t realize how cold it was going to be (which I think is a little silly) and didn’t bring much warm stuff.

The first things we saw were more elephants – two more bulls traveling together. Hein also took us on a short walk to see to some elephant bones. This female elephant was one of the lucky ones and actually died of old age. They live about as long as humans do – up to 70 years. Even years after they die, the other elephants will drag their bones around and spread them around. Hein said this was a sign of respect. A few of us took pictures holding Hein’s gun next to the elephant bones – which was a little silly. Being medical people, we also spent some time trying to figure out exactly which bones were which - there were maybe 5 large pieces strewn about. The skull was easily identified of course (it has a huge nasal cavity!), but the rest of the pieces were a little tougher. We thought we identifed the hip bone and maybe a femur, but we were just guessing. Hein thought we were funny. :)

Then Hein took us to a fenced enclosure to see these 3 wild dogs that the park was releasing in a few weeks. They looked like they could be pretty savage animals – I’m glad they were fenced in. There’s already one pack of wild dogs in the reserve, and I think Hein said they were hoping that another pack would form. Hein said that the existing pack once took down a rhino! And they start eating it before it dies, and he said it was pretty brutal – it was several hours before the rhino finally died.

We finally also saw some zebras – there were 3 or 4 of them right next to the trail! They weren’t too scared of us – we stopped right next to them to take pictures and they didn’t run away. Kiona really liked these, and I thought they were cute, but nothing that great. We had a break where we had coffee and tea, and Kiona did some acrobatics. :) And finally, we saw some white rhinos in a pack. They were a little away from the dirt road, so Hein took us off-roading (which he’s not supposed to do) to get a little closer. They were pretty skittish and ran away a little bit when we drove up, but we still got pretty close to them. We saw a few other deer-like things, I think kudu, but they were mostly running away from us and we didn’t get a good look.

When we got back, breakfast ready! It was a huge buffet of eggs, pancakes, bacon and sausages, fruit, cereals, sautéed mushrooms, breads, breakfast pastries, and I’m sure a ton of other things I can’t remember. It was great, especially the sausages. I really can’t say enough good things about the sausages here. It was also somebody’s birthday and towards the end of breakfast, the entire staff came in dancing and singing, bearing a birthday cake! It was a pretty impressive scene and must have lasted close to 20 minutes. One song would end, and they would start another one. It’s amazing how well every single person can sing, and even harmonize.

Then it was time to leave… Goodbye Tau!

It was a super busy weekend already, but it was Steve’s last weekend in Botswana (although he will be coming back in six weeks) so Michael organized a Braai (barbecue) at ICC flats (where we live) and had Steve and Barry over. None of us were hungry, but we had a huge amount of meat again. And Steve made bananas foster, served with ice cream for dessert. He also made a little speech saying how well we were all doing, and how well we had adjusted to everything – I bet he gives a similar speech every time he leaves. :)

It’s actually very nice outdoors – our flats have a large outdoor area, which includes a pool, a large barbecue pit, along with smaller grills, tables and chairs, and shaded wood benches for sunbathers to lie on. It’s also very nicely landscaped, with all sorts of different flowers, plants and trees around. I think it takes quite a bit of water to keep it up, which is a commodity here in Botswana. It actually rained for about 5 minutes! I bet Motswanas were overjoyed for a split second. Apparently last summer they got a ridiculously low amount of rain, something like 3 cm. And they need the rain.

A traditional Botswana dinner

We were hoping to go to Mokogolodi game park today for a game ride, but it turns out they were all booked. So it was a pretty chill day, which was nice for a change. And to my surprise after the night before, I actually didn’t feel too sick when I woke up. I thought I was going to get a raging cold, with maybe fever and chills, maybe GI symptoms like other people had. But it was mostly a super sore throat with congestion. I stayed in my PJ’s until noon, and then threw a Frisbee around with Lisa and Kristy for about half an hour. Then I took a 2-second dip in the pool at the apartment complex – it was freezing! I guess the nights are still pretty cold here and the pool doesn’t have enough sun or time during the day to gather any warmth. But laying out in the sun felt pretty good. I also managed to set up my blog for the first time, and took a nice nap.

For dinner, we went to the house that Dr. Gluckman and Dr. Nathans are staying at (Malek house) where they cooked us a traditional Botswana dinner. It was soooo good. We had chakalaka, which is actually a vegetable stew dish with all sorts of different Botswana spices. You can buy it in a can, and it's still really really good - you can dress it up some, add some stuff to it, and it can also come with beans added, or other things, and it’s just really good. We also had this thing called sampa, which is a starchy corn dish that you eat with all the flavorful stuff. Also on the menu were beets, salad, veggie skewers and of course, the barbecued meat. The meats here are amazing! I especially like the sausage here, but they also made barbecued chicken wings with a special sauce, and beef skewers. They just have so many different types of meat in Botswana - beef, chicken, fish, ox, goat, livers, and other types that I can't really think of right now, and they cook them all so many different ways! I wish I knew what spices went into these dishes so that I could replicate them when I get back to the states.

So at the dinner, I ate until I was stuffed! Man, I thought I would be eating less here in Botswana, which turned out to be true the first few days, but now I'm eating even more! It's a problem. But not one I'm super upset about. The thing is that lunches here are so cheap and huge and chock full of meat. You can go to the cafeteria and buy this huge lunch for the equivalent of $3 or you can go outside to these ladies with pots of food on tables and buy similar food to what's in the cafeteria for the equivalent of $2. And it's all meat laden (although you can just get vegetarian if you want - and the veggies and salad are amazingly good too), and huge portions. I always eat it all too, it's just soooo good. I usually eat such a huge lunch that I'm not very hungry for dinner, but that's good - I don't need to be eating a big dinner when I have such a large lunch.

Water in Gabs

We went to the yacht club today after work, and enjoyed a gorgeous sunset. I went with Amy, Michael, and Michael's fiancee (whose name escapes me at the moment). It's set over the Gaborone dam, and people can take boats out on the small lake. The yacht club itself is pretty nice - the clientele is almost entirely made up of ex-pats. They serve plenty of alcohol, and some food that they mostly warm in a microwave or grill. Apparently it gets quite crowded on friday and saturday nights usually, but tonight was unusually calm.

This dam provides most of the water for Gaborone and the surrounding area. Right now, the lake is super super low, which you can see by the water line. Last year, Gaborone (and the rest of southern Botswana) experienced a severe drought - they had a ridiculously low amount of rain. I think it was 2.5 cm or something like that for the entire summer. And the couple of years before that was not great either. I think the last time they had great rain was 4-5 years ago. And before that good year, there was a drought for a period of years as well. So it's been relatively dry for southern Botswana for the last decade or so.

As a result, a lot of people have stopped farming and are trying to eke out a living doing other things, usually in urban centers. Cattle look really skinny because there's nothing to eat, and livestock of all sorts are not doing well. It rained for about 5 minutes during our braai last weekend, and everyone was jumping for joy. Rain and water is so important that the word for rain, "pula," is also the word they use for money. That's also what you say when you raise your glass in a toast, like "Cheers!"

Hopefully this year Botswana will get lots of pula!

Sitting at Tau

This was such an exciting trip! Tau is a lodge in the Madikwe game preserve just across the border in South Africa. It’s basically like a resort – they pamper you, feed you extremely well, and in between meals, they take you on game drives.

We left for Tau at 10:30 am. Steve drove all 10 of us (Barry, Mike, Tara (Mike’s fiancée), Lisa, Kristy, Kiona, Josh, Anne, Betsy and I) there even though he wasn’t staying himself. We all squished into Gill’s (she’s the administrator for this Penn in Botswana program) Land Rover, which fits 10 tightly. It’s not that long of a drive – maybe 30 minutes to the border, then you have to get out, get your passport stamped on the Botswana side, walk/drive to the other side, get your passport stamped on the South Africa side, and the Madikwe game preserve is right there! But we had to drive another 20 minutes or so on dirt roads to get to Tau Lodge.

The pampering started immediately – we got out of the Land Rover and the served us glasses of champagne with juice. They gave us a little tour of the main area – there’s a big building that is located centrally, with 15 huts on either side of it. The capacity of the entire lodge is 60 people (30 huts). Inside the main building there was a large dining area and a large lounge on the first floor, complete with fireplace, gift shop, reception, etc. Upstairs, there is a large bar, with a TV, computer area, pool table, and more tables and couches to sit and chat at. This upstairs area opens up into a large outdoor porch that overlooks this huge watering hole outside of the lodge. This watering hole is amazing – more on that later. Outside, there was another large dining area, which surrounds this huge outdoor fire pit. There’s also a heated pool outside and more areas to sit and drink and hang out.

After this tour and explaining our time table, they took us to our huts, which were super posh. There were two twin beds with mosquito netting (which is just for looks) in a small room, heated blankets, a porch with a personal view of the same watering hole that you can see from the main lodge, a large bathroom with a bathtub, and attached to it, an outdoor shower! I never got to use it – but it seemed really cool. There is a large brick wall that shields you from the outside world, but the top is open to air. It would have been interesting to take a hot shower in relatively cool air. From the porch you got a great view of the watering hole, where animals would just walk up to drink from, and you couldn’t see any other huts or people. You’re protected from the animals by this electric fence that I believe encompasses the entire game preserve – which is huge. But apparently sometimes the animals come right up to the electric fence, which is only a few feet from you!

So that afternoon, after settling in our rooms, we sat around for about an hour first on the porch of the main building and watched the watering hole. It’s amazing how many animals you see just sitting there! It was really nice weather, and these animals just come up to the watering hole. We first saw kudu, which are deer-like animals – they’re probably the most plentiful mammal at this game reserve. We only saw the male, although Steve said that often there’s a female following several yards behind the male. It was amazing, just sitting there on the porch watching the water hole, we also saw hardebeest, a family of wild boars. The boars were pretty skittish and they run funny… their little legs can move them pretty fast, and their heads bob up and down and they keep their tails high as they run. We also saw a sable, which according to Dr. Gluckman, are very rare. They’re amazing animals though – very noble and statuesque. And finally, we saw baboons! I know Pete would say ewwww! There was a huge clan of them, maybe 20 or so. And there was one huge old male baboon that mostly just sat around while the younger ones climbed trees and played around.


There were also tons of birds, which I can’t even name. We saw a Jesus bird, which has a more indigenous name that I can’t remember. It walks on water. There were some big hawks, and white stork-like birds. These little birds, called weaver birds, build these really cool nests in the trees. They build them at the end of thin branches, and they hang there, like a big drop of water. Apparently, the male builds the nest, and if the female doesn’t think it’s up to snuff (probably because it’s not sturdy enough or something), she knocks it down and he has to rebuild it! I find that pretty funny.

The hospital crowd

So more about the patients and the hospital… Working at the hospital has definitely been an interesting experience! The patients here are so different from the patients in the U.S. There are usually 8-10 patients in a cubicle, with about 5 cubicles in each ward. Often, a small office gets turned into a 6th or 7th cubicle to cram another 5 patients into. Sometimes patients don't even have a bed, they have a mattress on the floor, sometimes in the hallway, if it's too crowded. The ER never closes because the hospital is too full, you just squeeze more patients in. There is absolutely no privacy - you're lucky if you get a curtain to draw around a single patient. You do procedures at their bedside, often with other patients looking on. The picture below is one of the better cubicles (the "high-intensity" cubicle for sick patients - which is right in front of the nurses station should a patient need immediate attention) on a very uncrowded day. There are no patients on the floors and there are a good number of curtains up.

So the patients are crowded together, usually not more than a foot from each other, they have no TV, no books, nothing, and visiting hours are only from 6-7:30am, 1-2pm, and 4-5pm and 6-7:30pm every day. And surprisingly, the hospital and the nurses are very strict about the hours. So right at 1pm, all these friends and family stream in, and right at 2pm, they leave. They're actually sort of necessary because the hospital is so understaffed that often the family helps bathe the patients or feed them if the patients can't feed themselves. The patients come in pretty sick too, because they often don't want to go to the hospital until their symptoms are super bad. Despite all this stuff, the patients rarely, if ever, complain. They just sit there everyday and wait patiently for us to come see them, and to get better. It's such a change from the U.S. patients, who have such a sense of entitlement, and demand every little thing, even things like mashed potatoes for dinner or something.

Patients rarely sue anybody here, and they put up with a lot more crap than do patients in the U.S. I guess that’s necessary because I think mismanagement of a case is pretty common. I think there are a variety of reasons for it – number one being the fact that the hospital is way understaffed. There are not enough doctors, nurses, social workers, physiotherapists, anything you could possibly think of. I also believe (and this is almost definitely egocentric) that the doctors and nurses here are not as well-trained, and so there is some medical mismanagement because of that. The Penn people are very good, but the other doctors sometimes are just here to do their job and make money (not that it’s a huge amount) – they don’t put in the effort to learn, teach, or really help patients get better. I’ve seen so many patients come in with congestive heart failure get put in fluids, or people with focal brain tumors that are obvious on physical exam, get diagnosed with meningitis. It’s a little embarrassing sometimes. Of course, when you get 10 admissions in a night, and are covering 100 other patients, sometimes it’s difficult to do an appropriate workup of a patient. But still, the lack of knowledge can be appalling.

There’s this one M.O. (a doctor who has only finished internship only) the other day who was getting grilled about a patient during intake as she was presenting. The patient had right upper quadrant abdominal pain, and she gave her differential diagnosis as pneumonia. Horrible. When the chief of the hospital asked her what else it could possible be, she could only answer pneumonia… so then he asked her what organs might possibly be in the right upper quadrant. She said spleen. And that’s all she could come with. And this is a doctor! Awful.

The nurses here are also very different. They don't do much here - they don't do IV's, blood draws, put in foley catheters, etc., so you have to do it all yourself. Believe it or not, I actually miss the nurses at HUP. :) I guess some things are still the same – some nurses and good, some are nice, some are moody, some refuse to do anything. There’s a whole variety.

The diseases we see here are different too - we see a ton of HIV and advanced AIDS-related illnesses here: TB (which can be anywhere), cryptococcus (which can be anywhere), PCP pneumonia, different cancers. I'd say about 75% of my patients are HIV positive, which allows a lot of this other stuff (TB, PCP, cancers) to happen. Botswana actually has a free HIV medication program (which is a whole separate topic for a different day) for all of its citizens. Even so, many of the patients refuse to take their medications and instead take traditional medications. They’ve caught patients throwing their medications down the toilet or in the trash before. And sometimes these traditional medications – we have no idea what they are – cause kidney failure or liver failure! I guess that’s the most frustrating thing about these patients, even though they are super nice and appreciative, and their families are by and large amazing in terms of support.

In general, there are so many patients you just can't take care of all of them - some stuff just has to slip through the cracks and you have to let it go. You're already working twice as hard as many of the Botswana doctors and at some point you have to go home, but that means some patient is probably going to die. Luckily I didn't have anyone die on me for my first two weeks, but it's really just luck - almost every team has an average of one patient die every day or two. I will probably have a patient die on me this weekend because there’s less care during the weekend. There’s usually two people covering all 100 patients, and they are really only required to see the sickest ones. It’s also difficult if they admit 10-30 patients over the weekend to see the other sick patients already on the ward – they are just so busy! However, other people just don't take as good care of your patients than you do when you're actually at the hospital. And any signout you give to the covering doctor doesn't usually get done, but it depends a little on who you sign out to and who’s covering the weekend. I guess these things are just things you have to let go because you can’t be at the hospital all the time.

Pelagano art colony in Gabane

Today was a huge adventure! Lisa and I wanted to go to Gabane to see the art colony there and maybe buy some stuff, but we didn’t really know how to get there. We got the general directions that we had to take a combi to the combi station, walk over to the bus station and take a bus to Gabane. The combis are an experience in themselves! It’s Gaborone’s mass transit system, and it’s really just a bunch of rickety private vans that go on specific routes. They pack in as many people as humanly possible into each van, usually about 15 people, with people almost sitting on each other or crouching in the van. But they’re very cheap, only P2.5, which is like 40 cents. There are certain stops, but you can really flag them down anywhere, and you have to know where you want to get off because you shout it to the driver.

So first we get on the combi going the wrong way. We have to get off, cross the street, and flag down a combi going the opposite direction. Oh no, another 40 cents. :) Good thing for us, the combi stop is the last stop – and there are rows and rows of combis. It’s a pretty amazing site. Good thing we met this guy Reuben on the combi because he then took us to the bus/train station, which is across this big foot bridge – we would never have found it on our own. Or at least, it would have taken us a lot longer! And there are about 200 lines of different buses waiting to go to different towns and cities. They all say the name of where they’re going on the front of the bus, which is helpful, but he led us to the right one for Gabane. And these buses aren’t really buses – they’re really just combis, maybe a little bigger. And we squish in, and once it’s full, we were off for Gabane! Again, we rode it to the last stop, which took about 30 minutes, but we definitely did not see any art colony. So we had to ask around – good thing there are at least a few people who speak English and almost everyone is very willing to help out lost tourists. A guy basically told us that we had to walk 2 or 2.5 km down this dirt road to get to the art colony at the base of a hill, and that it was called Pelagano.

It’s not as desolate as it sounded though – there were cars that went down the road from time to time and people walking down it along with us. Every once in a while a car would honk at us and look, I think expecting us to hitch hike. We almost did it a few times, but it wasn’t that far to walk. It was pretty interesting too - there are domestic animals (donkeys, sheep, cows, etc) wandering everywhere, and we got to see what type of places normal Motswana (that's the term for someone from Botswana) live in. Most of them live in these cement square rooms, with an outhouse in the back. Some of them have thatched roofs. But they look tiny, and I'm sure a whole family lives in there, with a small stove and everything all squished in. The picture I took was of a really nice one with a store attached to it at the back. These guys kept coming up to us and chatting us up too. Most asked if we were single and things like that, but there was one guy who kept asking us if we wanted to buy his property! Pretty funny.

When we got to Pelagano, it seemed pretty deserted. But we wandered into one of the open doors, and met this artist Elijah. He was surrounded by all these large, nearly-life-size sculptures, and was working on this huge clay scorpion on the floor. We found out that most of those huge sculptures were made of fiberglass from molds that he designed – he also designed the outside entrance to the art colony. He seemed really talented! He had beautiful works in clay, fiberglass, metal, and watercolor, and we probably only saw a small portion of his work! And apparently he had a twin brother who did a lot of art as well – I think mostly glass-blowing. But we didn’t meet him. Anyways, after talking to him a bit, we wandered around. It was pretty empty, but he told us that it was much busier on the weekdays, when the colony was more open. It didn’t really matter though, people would see us walking by and invite us in. And the glass-blowing and pottery shops were also both open. It was very impressive stuff – if I didn’t think some of it would break on the trip back, I might get some of it. And it was not nearly as expensive as in the states, although it was probably expensive by Botswana standards. We ended up buying some stuff from this boy artist that looked like he was 13! He did some amazing stuff though – he painted on cloth, and he had wall hangings, linens, etc. The wall hangings were the most beautiful, but I already have so many that I can’t even hang up. Lisa bought a wall hanging and I bought these cloth placemats. Still super cool.

Past ICU stories

Today was just an okay day – the whole ICU thing sorta blew over, so it was alright. Dr. Stefanski basically said that no female student should ever go into the ICU alone, and he, Boipelo and I all went in to the ICU as a group to see our patient today. And the doctor was very civil. They both told me all these stories about this ICU doctor. Boipelo told me that when she was an intern, she had a patient in the ICU, and this doctor said “go away, and never talk to me again! I don’t talk to interns.” And that’s just crazy! Often an intern is the only person taking care of the patient!

Dr. Stefanski also told us a story about how he had this critical asthma patient that he transferred to the ICU. The ICU doctor refused to use epinephrine on this asthma patient, who was breathing like 50 breaths per minute and really struggling. And for those of you non-medical people, epinephrine can be a huge life-saver for asthmatics – it can open up your airways until the attack has died down a little bit, otherwise patients can literally suffocate to death. Anyways, the ICU doctor refused to use it because he said it was never done, and there was no proven benefit. So Dr. Stefanski got two big legitimate papers that described in large multicenter randomized studies that epinephrine was of benefit for severe asthma attacks, and he gave them to the ICU doctor. The ICU doctor just threw them away. Apparently, the patient kept going in her awful suffocating state for about 3 or 4 days, and then the ICU doctor finally said, okay, she’s not getting better, maybe we should try the epinephrine. And the day they finally tried it, it was basically too late – the woman was so tired from breathing so hard for so long that her body just gave out and she died. I would say that this ICU doctor was personally responsible for this woman’s death, which was very preventable.

Oh, and in case anybody cares, his name is Mkubwa. So if you ever bump into a Dr. Mkubwa that runs an ICU in Gaborone, Botswana, I hope it’s not as a patient.

The supply chain in Botswana

This was a relatively boring day at the hospital since this is our easy week, so maybe now I’ll talk about some another issue at the hospital – the supply chain! This is a favorite topic of Dr. Stefanski's, so we've had quite a few discussions about it.

So here at Princess Marina Hospital, probably the largest public hospital in Botswana, there are often problems with the availability of medicine, or of certain medical instruments, even very common ones. Last week, we ran out of amphotericin, which is a drug we use to treat cryptococcal meningitis - that's an infection in the cerebrospinal fluid that surrounds your brain and spinal cord. It's the type of thing that we diagnose with an LP, which I described in previous posts. Because a lot of people have HIV and AIDS here, a lot more here come down with meningitis than in the states - some of it is due to TB, some bacterial, some bacterial, but more often than not, it's due to cryptococcus. And amphotericin is really the only option they have in Botswana to treat it. Alternatively, you can use a whopping dose of fluconazole, but it doesn't work as well, and we also ran out of that for a few days last weekend. As a result, all these people in the hospital (and in the clinics probably) had no amphotericin, and also no fluconazole - their cryptococcal meningitis went untreated! Now, even if they had come in immediately and started treatment right away, this is an awful disease, and chances are not great that they'll survive. But if treatment is delayed or halted for a couple of days, chances are even worse! Our team didn't have anybody die, but I know other teams that did.

Dr. Stefanski told us this story about how last year, they ran out of the solution needed for peritoneal dialysis, which is a substitute for your kidneys, if your kidneys have failed. Dialysis isn't as common here as in the states, but there are still quite a lot of people on it. And they were out of it for a month! People were basically getting admitted to the hospital to die of kidney failure. Awful.

Apparently, the problem is not lack of money - the ministry of health has plenty of money. It is the largest ministry in Botswana, and controls the largest budget by far. The problem is that somebody or some group, whoever is in charge of ordering medical supplies for the country, did not realize that we were running low on drug X, or medical supply Y, and didn't order it. So the entire country will be out of whatever it is for a month at a time! Supposedly, they've had 3 big consulting companies (probably each making millions of dollars each time) come in and make suggestions as to how to correct the problem, but obviously that hasn't happened. It seems that every time there is a change in who's in charge, they get a new consulting company in (probably they're friend or relative's company) and get new recommendations, which aren't followed. It's such a ridiculous problem, and a very exasperating one that all the doctors complain about. I guess it's another thing to be thankful for in the States.

Faith in American patients

Today may have restored my faith in American patients. Way back when, I posted about how much better African patients were than American patients. Today was my first day of internship and I was prepared. I was prepared for the gripes from the patients: "My cable TV isn't working!" "I asked for mashed potatoes for dinner, not broccoli!" "I refuse to take that medicine!" "I demand a private room!" And of course, I was not expecting any gratitude or help with the patient care from the families. I was not even expecting the patients or their families to know anything about their own illnesses. I expected a lot of drug addicts, HIV patients, gun-shot wound patients, people with no family support, rudeness, impatience, an air of presumption and expecting things they should expect.

I was surprised. Three of my patients or their families expressed extreme gratitude for my help. Some of them were pretty demanding, but in the end they were grateful for all that I did. A fourth patient started out pretty surly and unfriendly. To be fair, he's been in the hospital for close to 3 weeks, and he's not that much better yet. But after talking to him and joking around with him for a few minutes, he warmed up, and even thanked me at the end for talking to him.

I think in the end, you get what you put into the patients. They may be very demanding (especially compared to Botswana patients), but if you really care and try to help out, they'll see that in you and be appreciative. If you don't care about them, of course they're going to realize that and see that in you. Maybe American patients aren't so bad after all. Or maybe it's my first day and I'm still being naive. :)

Going to Gabs with the Senegalese President

I didn’t sleep too well in Jo’burg – must have been the time change. I think I slept only about 2 hours in all. Maybe 3. I definitely kept waking up every hour because I think I was worried that I would miss the pickup to the airport the next morning. The owner of the transport company was the one that came and picked me up! We had a pretty interesting conversation about Johannesburg, and he showed me the Chinatown on the way to the airport.

At the U.S. airport, they had told me to get to the Jo’burg airport 3 hours ahead of time. I was doubtful, but I got there about 2.5 hours ahead of time… nobody was even at the South African Airways desk! They didn’t even open until about 6:30am. And it was a little annoying – I had to wait in line to weigh my bag, and they gave me a little slip of paper with the weight. Then I had to wait in line for the agent to give me a boarding pass. But apparently they can’t do everything, and since my ticket had a different date on it, I had to go to a ticketing agent who put a sticker on my old ticket saying I was traveling on a different date. Then I went back to the first agent to get my boarding pass. I guess it was good that I had a few hours to kill.

Something interesting that happened was that I was trying to figure out how to get to my gate, and the signs weren’t very clear, so I asked a random security guard how to get there. He says “come with me” and I follow him. He took me through all the security checkpoints, bypassing the lines that the normal people had to wait in. And of course, as we were walking to my gate, he was walking with me, and I was sort of trying to figure out how to get rid of him, and he asks for my phone number and to be taken to the United States. I eventually got rid of him by asking for his phone number and saying that I didn’t have a phone number yet. It was sorta funny. :)

My flight was the first flight of the day out of Jo’burg to Gaborone, so I wasn’t too worried about delays and things like that. We were waiting, and nothing was happening when we were supposed to be boarding, and then they kept delaying the take-off of the flight 15 minutes. In the end, we were delayed about 45 minutes, which I thought was pretty odd, given that this was the first flight of the day. It turns out the president of Senegal was on the plane! We didn’t know though, until the end of the 1-hour plane ride. They just called them VIPs. And they made a few people move so that the VIPs could move up front and disembark first. But they did not make me move, so one of the people in the delegation sat right next to me. He knew no English and I knew none of his language (Senegalese). The only thing we had in common at all was French, and my French is really really bad since it’s been about 12 years since I learned it. But he got it across to me that the guy sitting at the very front was very important. So we start to land, and I see one military guy standing alone in a field – I thought that was pretty odd. Then I see a row of 5 cannons (which apparently fired as we were landing), and military people! Then the guy sitting next to me says that all of this is for the guy at the front, and we roll to stop in front of a red carpet that leads to a raised platform. And there are people standing with umbrellas on the platform, and all these soldiers and a military band in front of it. Behind the platform are all these people watching, and press I believe. The guy gets off with all these cheers and the music going, and they proceed to the raised platform to meet the Botswana president, and the Botswana military puts on a whole show with music and marching and everything! It lasted for about 15 minutes, and we watched on the plane. I took a few pictures of it, but had to stop when the flight attendants told me I wasn’t supposed to. :) Dr. Gluckman picked me up, along with the resident, Sarah.

By the time I got to the ICC flats, I was super tired. I think I’d really only slept 4 or 5 hours in 2 days. I had to stay awake for about 2 more hours for this orientation meeting Dr. Gluckman gave us, but once that was over, I took a 3 hour nap while most of the others went hiking up some hill where you have a good view of all of Gaborone, and ended up going to one of the three malls, Game City, where they saw baboons running around!

I eventually woke up, and everyone was still gone. I went to local grocery store, Choppies, which is about a 10-15 minute walk on dirt sidewalks, and bought a few things, came back, and Lisa and Phil were making a yummy vegetarian dinner. Which reminds me, I had bought some beef jerky at the Jo’burg airport – it was so good! And I hung out for a bit after dinner with Lisa, Phil, Josh, and Mike. Tim was there for a bit too but he was leaving the next day. Then I sort of got ready for work as best as I could and went to bed. I slept pretty badly though. I went to bed at 10pm, woke up at 12am, and couldn’t sleep again until 4am. So I didn’t start off my week so well, but I guess I have to expect some of that jet lag.

The San-people resettlement villages

On the way back from the CKGR (Central Kalahari Game Reserve), Jo took us to see a resettlement village of the San-people. The San-people were removed from the Kalahari Desert years ago – maybe not physically, but many of them were told to move and intimated out of the Kalahari and relocated to these settlements where the government provides them with free water and maize, education, roads, and a variety of other free services. So now, the San-people live on 3 main settlements in Botswana, but they really have nothing to do! The government tried to teach them to farm, but historically they are a nomadic group, and there wasn’t much motivation for them to learn farming or keep up with it once the government left. There are no jobs for them, but even if there were jobs, popular opinion is that they probably wouldn’t be interested in taking them. The government provides everything for them – food, water, shelter, so there’s not really a reason for them to work or go to school.

There even seems to be a degree of resentment among the other Motswana – they say that the government gives everything free to them, and if they want to go to college, they’ll pay for them and everything, but they don’t even take advantage of these things! Instead, they sit around all day, and they make this drink called Chibuku. The San-people get free water, sorghum and maize, so they use some of it to make this very strong alcoholic drink. They mix it together, dump in some termite mound for yeast (the more termite mound, the stronger the drink!) and it only takes a day or two to brew. They’re often drunk by noon or 1pm because they just sit around and drink all day and hang out. We visited one of these Chibuku establishments (a bar) and actually got a carton. It’s not bad – a little sour and mealy, but it’s ok. It was definitely very strong. Jo said that after you drink two cartons, you’re drunk. It was only about 11 am and many of them were well on their way to being drunk. It was a little sad.

So how did all this happen? The government made up some excuse about the roads not being good enough in the desert, so the San-people had to move (not that the San-people used roads anyways, or not that the government couldn’t have build the same roads that they built for the San-people’s resettlement out in the Kalahari). The rumor is that the real reason the government relocated the San-people is diamonds, which were discovered in the Kalahari. Some of the San-people have won the rights to move back to the Kalahari, but now the government is saying only those 200 or so whose names were on the legal suit are allowed to move back. So they had to sue again, saying (rightfully so) that they represented all of the San-people. They eventually won, but by that time, the government had been providing so much free stuff now to them that only the older people want to move back. The young ones just want to stay on the resettlement grounds and stay drunk. It’s a very sad story.