Zimbabwe, not for the faint of heart

From Chobe I transferred across the border into Zimbabwe to see Victoria Falls. One of the seven natural wonders of the world, Vic Falls has grown into just the sort of tourist trap that you would expect. There are 10 hotels, 2 grocery stores, and 13,000 specialty shops selling t-shirts to the market demographic that the Hard Rock Cafe used to dominate, along with the usual trinkets and Shona sculptures. As we come into town the driver points out that 100,000 people live in Vic Falls. When he says they live in Vic Falls, what he means is that they live in the slums barely visible behind the thick skirt of bush. We fly by on the tar road; from the window you can spot the occasional lean-to fabricated from plastic sheet, canvas of cardboard if you’re looking.

Like everyone else, I motor into town in an insulated, air-conditioned bus. This is the kind of traveling that makes the ladies at the bridge club comfortable. Everything looks safer behind the glass. Until a hawker with some Zimbabwe dollars slaps them against the pane, pleading for a sale. In 2008, the annual inflation rate in Zimbabwe was estimated at 14,800%. It is unclear if this figure was accurate because at the time, there were not enough goods on the shelves to perform a price comparison. $10 million dollars could be exchanged for 6 USD. Now, the Zimbabwe dollar has disappeared, relegated to novelty status, and is slapped on the windowpane of every passing motor coach. 100 trillion dollars. Please buy it for 1 USD.

So after my one hour hike though the falls, one of the most beautiful places in the world, I wander through town, watching fellow tourists buy “traditional” African trinkets and listening the ubiquitous sounds of the  Lion King theme song. I sit on a bench and a hawker sits next to me. He likes my shoes. He motions to his, two sizes too small, and points out that his toes are curled under themselves, stretching the fabric taut. He likes my shirt, too, and wants to trade. I demand a wooden hippo the size of my arms spread wide. We strip a low hanging branch from a nearby tree to confirm the length of said hippo.

The following day he arrives at my hotel as promised, with two large and unsmiling friends, and three hippos. He no longer wants my shoes, or my shirt, but only money, to the tune of $250 USD. Did I mention yet that Mastercard is not accepted in the entire country? A British tourist told me that Mastercard is headquartered in the UK, and Mugabe hates the British. Or that I have only Mastercard? I offer him everything I have: 50 pula (7 dollars), 1 USD, one pair of stylish Kenneth Cole sport sneakers and tow t-shirts. Voices are raised. I will not get the hippo.

A security guard saves me from coming to blows with this man just as he starts demanding all of my money for his time. The same guard tells me later that they patrol the property at night and shoot anyone running in the bush. No questions, just aim for the leg.

Puku Flats, the escape from Disneyland

I could easily exhaust my supply of superlatives attempting to describe the beauty of Chobe National Park. The vast 11,000 square kilometer park is nearly all desert. In the dry season, the Chobe River is the only water for miles. There are 60,000 elephants in this park, and it seems as if they have all come to drink. Unfortunately, the Chobe and the nearby Victoria Falls world heritage site have become a popular two day trip for travelers from around the globe. The pace is regimented: morning game drive, break for lunch, evening boat cruise, sleep, transfer to the falls, snap photographs, go home.

My first evening in Kasane, I found myself on a boat cruise with 39 of my new closest friends. Twenty-five of them are college sophomores from the States on exchange. I swear, they follow me everywhere, punishing me for unknown prior transgressions. They come toting two ice chests crammed to the brim, chanting “booze cruise, booze cruise”. It looks unbelievable when I write it, so I have to reaffirm, they really were chanting. Before the boat leaves the dock they are rummaging through the chests.

We set off down the river into the park and quickly join the flotilla. There are two other pontoon boats equally as full, although no one is doing jello shots or keg stands on those boats. Just my luck. There are a number of smaller craft ferrying the more monied, nimbly maneuvering between the larger craft, stopping at the best sightings, and then roaring off again. We churn the glassy water into chaos. The sound of the birds are lost amongst the growl of the outboards. But we snap some nice photos.

Luckily, I met Simo on my walk from the boat back to my hotel. We negotiated a full day game drive, and he drove us deep into the park, well beyond the reach of the daytripper crowd, to the Puku Flats. After a while, we stop seeing cars, or boats, or anyone at all. When we stop the car the only sound we hear is the wind and the warbling birds. We are often silent, each in our own reverie. The zebra gallop into the brush at our approach, and I realize how novel it is to find wildlife here that retain their healthy fear of humans. This is no carefully staged menagerie.

We must do something about the goats and porcupines

The morning report at Mochudi began much the way it begins in PMH, with a census. There were 12 admissions overnight, 4 four for gastroenteritis and IV fluids. There were a total of 63 patients in the hospital, of which 8 were expecting mothers. And then it became interesting. There were 13 goats lurking in the shadows and coming out at night and frightening the doctors and nurses. There were an unknown number of porcupines, of which they were all the most frightened. Overnight security had been called to disperse the goats, but he did not answer. He, like the physician scheduled to take call that night, did not show up.

After morning report I am shown my clinic room. It has no lights. There is a window, which has been shattered. When we close the blinds and ask someone to disrobe, we sit together in the dark. The hollow clang of the bells around the goats’ necks, the hot still air in the clinic room and the soft hum of the hornets in circling aimlessly provided a surreal backdrop to what was otherwise a commonplace clinic without surprises. There was only one sick patient, for whom we had been trying to provide methotrexate. Many phone calls later, I discovered that while methotrexate was in stock at the Marina, they would never ship any to Mochudi, preferring instead to hoard the supply for the patients in Gabs. So I sent to Gabs to pick it up.

That was my last day. I finished clinic, bought a papat (home-made english muffin) and a Fanta, and watched the cows graze in front of the hospital, and watched the goats blissfully ignore the shouts and claps of the hospital security. I have finished my time in the hospital, and survived.

I’m writing at this moment on the banks of the Chobe river, where the beauty is so overwhelming, it seems as if it cannot be real. It is a nice respite.

Bird on a Wire

Listening to Leonard Cohen sing Bird on a Wire might be perceived as a maudlin start to a downhearted day, but some days it just fits. Last week, I had many such days.

Doreen had come to clinic several days before, her waistline burgeoning with dreams, fantasies and incipient life. She had the glow and sparkle of a woman in her third trimester, as if she were completely in tune with the world of possibilities that awaited her and her unborn child. The joy and anticipation were palpable. She came to me because she had a rash. Doreen had HIV; in an effort to protect her baby from the same fate, she had been started on AZT. Two weeks later, she was red, blotchy, and itchy. I sent her away with ointment, reassurance and a smile. A week later, I was consulted from the maternity ward for a woman with a rash. Her eyes were a baleful yellow, and she stared at me with lidded unblinking eyes. Her skin was sloughing, she couldn’t swallow or talk. I didn’t recognize her until I saw my own handwriting in the chart. Gone was the glow, the joy, the life. I asked for a liver panel. Every day for a week, until it was drawn. Two weeks after I had sent Doreen out of my clinic with a tub of steroids, benadryl and the false confidence that she would improve, she was admitted with fulminant hepatitis. I found out later she had lost the child. It was buried, with a small piece of my soul, and a good piece of my confidence somewhere close by. To say that I was shaken would be insufficient.

When I was in medical school, I delivered a baby who had died. One day, he had just stopped kicking. His mom had carried the weight for a month, dreading and anticipating the moment when it would be over. I remember her perfunctory pushing, as if she were struggling with the inevitability, as if delaying the moment when she saw the body would make it not so. When I saw his head, blue and gray and stained with meconium, with the cord wrapped three times around his neck, I cradled it the way I had been taught. I gathered the body and held it in my arms. No cry, no sound at all. Just soft tears rolling down his mother’s cheeks. We said nothing before I backed softly out of the room, feeling like an intruder. It was impossible not to feel that woman’s pain and loss. The vision of her child is still with me.

I carry them with me, these women with their unflinching eyes steeled by tragedy that I can not hope to fully understand. And so I listen to Leonard Cohen sing Bird on a Wire, and try to make sense of it.

Sleeping on the moon

The Makgadigkadi pans are 12,500 square kilometers of salt flats. They are all that remains of what was once a great lakes covering the entire region in the center of Botswana. In the rainy season, the pans spring to life; zebras and wildebeasts migrate through by the thousands, and with them come the predators who feed on them. In the dry season, though, the pans a vast arid expanse of nothingness. After the week I had, I was craving nothingness and silence.

My first challenge associated with my trip to the pans was getting there. I flew into Maun, about 200 km away, and spent the first night at the Old Bridge Backpackers Lodge. True to the rumor, this was an amazingly popular destination for mostly South African ex-pats. They drank and caroused at the bar by the riverside until 4 am. I know this because my room, contrary to the rumors, left a bit to be desired. My roommate, a massive spider motionless on the wall at the foot of the bed, seemed right at home. The slew of frogs out my window bellowed for attention. I slept restlessly, dreaming of spiders, poorly washed sheets, scabies, and the bloody hand print on the wall. I woke before dawn and found one of the Mokoro guides still up, drinking wine from a metallic sack, warming his feet by the fire. I made a mental note to cancel my upcoming mokoro trip, and head to Vic Falls instead.

After a breakfast of tea, I walked out from the Old Bridge to the main road and caught the Combi to the bus rank. At the bus rank, I was reminded that unemployment is reported to be 30% in this country. We were assaulted by women selling bananas, sodas, chicken and chips, cellphone minutes, candy and water. They came in waves, like impromptu battalions, hawking their wares, calling out again and again and again. The bus pulled out of the rank, and I found myself wedged into a seat half my size. I felt the warmth of my neighbors’ skin from ankle to shoulder as we silently pressed against one another. I started sweating, losing precious moisture as the Kalahari air howled through the open windows and snatched it off of my skin. My lips cracked, and I thought maybe I should’ve bought some of that water. 50 km, a momentary reprieve: a security checkpoint. We filed out of the bus with our bags in tow. My turn in line arrived, and the woman behind the folding plastic table on which our bags are being gutted opens every zipper, pulling out every item. Finally, she triumphantly held up my sandals, shook them at me and said, “you must dip it!”, gesturing to the shallow silt-lined pool of water in which I saw passengers lining up to submerge their shoes. I was confused but followed suit. Meanwhile, our bus is driven through a large dip in the road filled with the same filthy water, a sheen of oil creating rainbows in the eddies as the bus rolls through. I found out later there is a foot-and-mouth disease outbreak near Maun. Apparently the government believes foot washing abates the spread of disease. It’s an aerosolized virus, but I splash my feet in the water anyways.

The bus drops me off about a mile from Planet Baobab, and I wander through the baobabs, their otherworldy bizarre contorted forms. Almost as soon I arrive, we are off again, this time on quad bikes. We set out on the bikes, instructed to follow the guide in a single row, tracing a well worn path along the edge of the pans. We pass of herd of cattle seeming lost in the middle of the wasteland. I can’t contain myself and race out for a moment towards the center of the pans, throttle maxed, a billow of salty smoke behind me. The feeling of freedom and limitless potential is overwhelming. I rejoined the queue and like the rest, choked on the trail of dust in the wake of those before me. We stop for a while at the meerkats, watching them assume their strangely humanoid posture and bask in the warmth of the setting sun. From the meerkats, we head 10 km directly towards the center of the pans. When we stop for camp the salt completely envelopes us, and the ripple of the gray soil, cracked and fissured like a river bed on the moon extends in all directions. The stars cast a soft light that bounced off the sand setting everything aglow. We all felt the majesty, and the only sounds for a while were the soft crush of the sand under our feet and the crackle and spit of the fire. And then the sorority girls on exchange at the UB starting talking about hazing the new pledge class and the moment was shattered.

The interweb returns, and a cheetah sighting

For three days now, I have been bereft of internet. I never realized how naked it would make me feel. Sunday was another pleasant day. The autumn sun grows in potency every day, and the air is starting to ripple with heat. I spent much of the day on the verandah, listening to the warm breeze, and trying not to check for internet connectivity. I am obsessive, and the uncertainty drives me insane. I am reminded of the pigeon I conditioned in college psychology class, giving him a pellet of food after the press of a lever. He tired of the game easily when every press of the lever yielded morsel of food. When the reward became random and unpredictable, pathos ensued. I watched through the glass as the bird scrabbled and clawed at the lever, furiously pressing again and again until the pellet dropped from the slot in the wall. Las Vegas was built on this principle. Click. Click, click, click. Still no internet. In a mission of self preservation, I called Justice and had him drive me back to Mokolodi. The game park is home to two cheetahs, supposedly orphaned by a rancher before they were capable of hunting. They have been hand-reared and live in a fenced sanctuary, ambassadors for the plight of the endangered species, or so says the sign on the cage. Still, inside with the cats, I get a little shudder of fear and anticipation. They are beautiful and powerful and it is impossible not to feel a sense of awe being so close to them.

 

 

 

A hike on Kgale hill

Kgale hill (1287m) lies just south of Gaborone. There are several challenges which must be overcome for a successful summit. The first of these challenges is the troop of baboons at the foot of the hill. Just like so many other beautiful places in this city, Kgale hill has been used roughly. Steps from the trailhead lie huge mounds of refuse, stacks and piles of garbage reaching the lowest hanging branches of the nearby trees. The baboons live here, scavenging the rubbish, Gaborone’s small version of Mozambique’s trash city. When we arrived, some scampered across the trail, while deeper in the brush they barked at us from every direction.We strode quickly through the scrub trees and tall grass, peering nervously into the impenetrable bush.

The next and most important challenge is navigating the trail. According to Wikipedia, there are three trails to the summit. None of these are marked. All roads lead to the quarry, and a confrontation with the guards, and a taxi home. At least so I had been told by my flat mates on arrival.

We successfully navigated the trail, avoided a foray to the quarry, and managed to scramble the final 100 feet of elevation. The vista was the sort inducing quiet reflection even in those not prone to self examination. We sat for some time, gazing out over the Gaborone dam, at the massive reservoir at its nadir at the end of the long dry season, at the miniscule cars racing down the black two lane highway stretching off into the horizon, and idly thought about the tiny fragment of the universe that our lives represent, and the tiny blip in time that our years comprise. Which is to say that we, or at least I, made the facile observation of our own inconsequence in the face of such majesty. And then I turned around and saw the mammoth boulders, littered with childish scrawl and inane drivel and I was jarred back from my reverie. But it was really pretty.

On the way back home we stopped at Game City, another of the many malls of Gaborone, for a much needed breakfast. We stopped in to the pharmacy afterwards. Next the herbal remedy for fever formulated primarily from belladonna, above the panoply of condoms in assorted flavors colors and sizes, were the cans of Mr. Big. In the pharmacy.

Kanye is exhausting

I did not post yesterday, as I was completely depleted by my Kanye experience. Just like last Thursday, my day began at 5 in the morning with a french press coffee so strong the spoon stood up in the cup. Justice arrived with the rising sun and hummingbirds nipping at the white blossoms on the tree outside the kitchen window, and we set off for Kanye. The town is 90 km outside of Gaborone down a two lane stretch of highway populated mostly by cattle, grazing in the tall grass on the side of the road.

We arrived at the hospital, where I delivered “grand rounds” consisting of an hour presentation on the language of dermatology (courtesy of Peter Lio). My audience struggles. They are verbal sluggards, accustomed to the monsyllabic descriptor “rash”, a term as useful as it is accurate. I try to impress upon them the inherent marriage between verbalization and conceptualization. Language is structure. Structure lends itself to differential, which lends itself to diagnosis. I think they understood every other sentence, but they seemed to appreciate the photos. After my presentation, I had clinic, where I saw 33 scheduled patients, and 2 old men that I did not have the heart to turn away. After clinic they asked me to come to the wards and see a sick boy with a rash.

Sekaetsewe is 11, and has had HIV since he was born. He was one of the many orphans of HIV in this country. As if a terminal disease acquired at birth from a mother who died shortly after were not enough, a few days ago he got toxic epidermolytic necrolysis. Somehow, at the Princess Marina Hospital, someone had dispensed efavirenz in lieu of combivir. Two weeks later, the pain in his eyes and mouth became sloughing and crusting. Burning pain seared his eroded urethra with every drop of urine. When I saw him, he was curled in a fetal position under a threadbare blanket in the corner of the room. No mother by his bedside. No family at all. Just a nurse who tended to him silently and perfunctorily, possessed of an impassivity foreign in its totality.

I am surrounded by patients with the worst skin condition we see, afflicting the patients already teetering on the edge, clinging to their tenuous health. I have so little to offer. We are accustomed, in the States, to the sense of control and empowerment afforded us by the tools we have at our disposal. As a resident, my expectation has always been that with sufficient study and preparation, I could treat nearly anyone. I could trace my failings in the clinic to a lack of knowledge or experience, not a lack of means. Here my inexperience and ignorance are compounded and magnified by the limitations of the system.I know that I have remarked on this sensation before, but sometimes it becomes overwhelming.

While my competence is being tested, I am also struggling to retain my empathy and my humanity. Seeing an eleven year old boy with no family, dying of a disease he inherited from a mother he never knew, faced with death before he can even comprehend the concept, should not feel ordinary. Yet it happens every day. Thursday a man hung himself from the side of his bed using a shoelace. He was lying feet from a nursing station and nobody noticed. The discussion in the doctors room at morning report was lighthearted and focused on containing the public relations disaster. The reputation of the hospital and medical officers seems to have suffered no ill effects from a prolonged strike during which scores of patients died, so it is likely a non-issue for everyone except the man, and his family, and everyone like him lining the halls.

The wager

Patients here walk through the door of my clinic room carrying their chart in one hand, and a disc of paper with a number on it in the other. The number, which has been dispensed by the triage nurse at the door, represents their position in the queue. They may have an appointment, or they may not. By the time they see me, they’ve sat in the waiting area on wooden benches of the sort that you might find in a county jail complete with a set of manacles, sometimes for hours. Perhaps it is during that time, sitting, patiently waiting, that they have the opportunity to adorn these charts with all manner of stickers, photos, and endearing messages. The novelty of a patient bringing their own medical record to my clinic quickly wore off when I realized the necessity of such a system (see Batswana Medical Records in a previous post), but the artistry and care with which these life records are personalized never loses its appeal.

You may find this post a little light on material. The same thought occurred to me as I was writing it. I blame the wager. Who knows how these things come up? I think I was euphoric from successfully concocting and ingesting fat cakes, and subsequently baking a 5 pound loaf of the bread Hilda taught us to make. We had just purchased a 5 kg bag of flour, 1 kg of sugar, several yeast packets, and a pound of margarine for the endeavor, and our cupboard seemed overflowing. Whatever the reason, I made the reckless claim that I could subsist for the rest of my time in Botswana, eating nothing but what was left in the pantry by those who have come before me. And the gauntlet was thrown. To take stock, we have: flour, margarine, sugar, 6 powdered soup packets, a half-empty package of pasta, coffee, black tea in sachets, 3 cans of beans, preserves, 4 eggs, a can of tuna, mayonnaise, one package of cheese, and loads of hot sauce. In the past 4 days since persisting in my foolishness as I am wont to do, I have eaten my homemade bread seven times. There are only so many variations one can make on this meal. More importantly, my days have devolved into work, sleeping (I think a diet of white bread and hot sauce has habituated my brain to a glucose feast/famine cycle necessitating copious naps), and walking to and fro. So I am raising the white flag of surrender. Tomorrow, after outreach clinic in Kanye, I’ll have Justice take me somewhere for a proper meal, and maybe a beer.

Spring has sprung

…or Autumn as they say here. It escapes me why Autumn should succeed Winter, but like many other things, I am learning to accept it and not question. With Autumn come the winds. They range from a gentle breeze, caressing my ankles on the walk to work, to a gale reminiscent of Chicago in winter, when the lake is whipped into a frenzy and the waves crash into the retaining wall, spraying water twenty feet into the air. It seems today that the wind will never stop, and with the winds come the dust. That rich red soil worms its way into every crevice, leaving a thin layer on my clothes, and wreaking havoc with my eyes. Even the sky is a muddier, hazier blue than the deep cerulean to which I have become accustomed.

There is still not a hint of moisture in the air, but somehow, the trees have begun to bloom. I watched the tree outside the kitchen window with the white blossoms vibrant in the light of the rising sun, drinking my morning coffee, and decided that renewal was in order. I walked the mile to work with a grin plastered on my face, and noticed that nearly every passerby returned it with a smile, or a nod, or a thumbs up. The groundsmen at the apartment answer my “dumela rra” (hello sir) with a “dumela rra o kae” (hello sir, how are you?), giving me the opportunity to use all three phrases of Setswana at my disposal, “ke teng” (I am fine) and “gosiame” (good bye). I was actually given a perfunctory Setswana “lesson” upon arrival, designed in theory to facilitate my rapport with patients. Like so many things, it was more form than function, but my photocopied page of phrases has come in handy, at least to break the ice with a good laugh at my pathetic accent.

Morning report begins promptly at 7:30, and as usual, is a farce. The patient presented today arrived at the hospital with chest pain and difficulty swallowing, and was found to have both cytomegalovirus esophagitis and thrush, or viral ulcers in the esophagus and yeast in the mouth. For the non-medically-inclined, these are opportunistic infections, almost diagnostic of immunodeficiency. In a country where 1 in 4 has HIV and who knows how many have full-blown AIDS, it’s an easy diagnosis, right? Well…the HIV test was negative, leading the astute resident to conclude that the patient had been immunosuppressed from antibiotics??? No further workup was performed. We had an extended discussion of why perhaps he had erroneously come to this conclusion, and made suggestions for further evaluation, at which point he mentions, “The patient is dead.” End of story. Or really just another verse in the same song. At the conclusion of morning report the acting director of the medicine service reports that Princess Marina Hospital is the top rated hospital in the region for patient care. I wonder what metric they used to gauge our excellence.

My renewal of optimism and enthusiasm was challenged, but not stripped from me. We round this morning, and miraculously, the TEN patient looks a bit better. Not because my orders were followed, as the order sheet on which I had placed those orders has mysteriously disappeared. Definitely not because she is lying in that filthy hospital bed. Perhaps she will make it through this after all, in spite of us. We write the orders again, and move on.