And Finally...

The Last Blog Entry

I’ve been working on this final blog entry for two and a half months. I started writing this entry from Swanage, England, as I made my way back from Lesotho to the US. I worked a little bit on it while staying with my family in Denton, Texas, and opened it up again while at a Mediterranean style restaurant in San Antonio. Now I’m in Santa Rosa, California, determined to finish what I started. My experience in Lesotho already seems so far removed from my current life. Possibly this is due to the travels I’ve had since returning - having made a road trip across the Southwestern US and working along the Honduras/El Salvador border. But maybe I’ve had trouble finishing this blog for more subtle, difficult to describe reasons. Part of me feels like this last blog entry should be a well thought out, all encompassing synopsis of my experience of living in the Kingdom of the Sky for the last year – wrapping up the advancements made, the joys shared, the loss and pain held inside, mostly out of reach. But I understand there are so many nuances of my experience there I’ll only begin to understand over the next several years of my life, if ever, I suppose. So, instead of waiting for it all to come into focus for myself, I plan only to recount my story, briefly and in simple sentences – and let the rest come as it may. Thanks for sticking with the blog for this long. Knowing that you cared enough to read made writing it so much more fun.

Cheers!
Jeff

I’ve now finished my year long stint in Lesotho. It’s seems so long ago that I began my time in Africa. Thirteen months have passed. I’ve learned much in this year, and I thank those of you who supported me during the hard times and that laughed with me during the fun times. What follows is a brief summary of the events of the last few months.

Anu’s and Kara’s departures
I missed Anu’s leaving, since I was still in the States on vacation. It was weird coming back to Lesotho without him being there. We learned a lot about ourselves and each other, and I am eternally thankful to him for his patience with me as a friend and roommate, as well as thankful for the time shared and love received from his family while traveling through India. When I got back from the States, not only was Anu gone, but Kara had moved out of the house! She was either tired of the bedbugs, or tired of me, but she did mention something about not wanting to leave Seema alone in her house, or something to that effect. In reality, Kara was in the country for a few more weeks. We had a fun time winding down, and it was great getting to meet her parents – who are as crazy and fun as she is. Lesotho will certainly miss the efforts put forth by Kara and Anu.

Leaving Mokhotlong
My last trip to the mountains went well. I kept to the same day to day routine that Tony and I had made for ourselves over the last several months. Some mornings were spent rounding with the local doctor on the children’s ward, but most of the time was dedicated to heading out to the rural health clinics to help the overworked nurses see the HIV positive patients while teaching them some new things along the way. It was nice to look back and see how much has been done over the year. More children and adults have been tested, put on treatment, and kept healthy. This has added up to us seeing many patients when we come, but we welcome the work since it means more people will be living longer, more productive lives. The nurses are in many ways more comfortable with caring for people with HIV, and Tony and I can see that as they become more independent, our presence in some ways will become less necessary. Even though I was ready

for a rest after long hours in the highlands, it was sad saying goodbye to a good group of people. The nurses and doctors welcomed me warmly a year ago, and I have grown to care for them and the future of Mokhotlong greatly. One of the biggest losses I felt leaving Mokhotlong was departing from the working relationship with Tony Garcia-Prats. More than anyone else, he was my mentor during my time in Africa. I wish him and Heather many continued blessings in their work in Africa.

Wrapping up at the COE
I spent the last month in Lesotho in Maseru, working at the COE, packing up, tying up loose ends (well, most of them), and reflecting on my year here. I was lucky enough to get to train a bit with Megan as she prepared herself for the Soweto marathon that she’ll be running in November. While I was still wearing my ski gear at night, the days were warming up considerably, making the weekend long runs wonderful – clear skies, temperature in the 70s, with a cool breeze helping us through the last stretches.

Good-bye events
As is tradition with the departing PAC docs, I said a short speech on my last day at the COE. It was nice to have a chance to thank all those that helped and shared during this year, as well as get to share my feelings on an amazing, difficult, and inspiring year in Lesotho. The next day we had a final party at the house at Happy Villa 4C – bean burritos, caipirinhas, cerveza Sol, good music and good friends. It was in a way the end of an era, now with Anu, Kara, and myself all gone from the house that took care of us for the year. Isaac, our guard and friend was there to say good-bye and also welcome in Tony and Heather, who will be living in 4C now.

Visiting London
I made the drive from Maseru to Johannesburg perhaps for the last time, seeing the rolling hills, wide open fields and sparse trees with a different pair of eyes. The overnight flight from Joburg to London was uneventful. I took a bus south west towards Southampton to spend a few days with Susie and Pete (of Kick For Life), and Susie’s family in the English countryside. We had a great time, from watching the Morrismen dance in the sea, tasting hand pulled British cask ales, climbing trees, exploring a castle, trying “chips” and “mushy peas”, and staying at the delightful B&B that Susie’s family runs. I spent the last day and night in London, going for a great run along the Thames – seeing London Bridge, the Parliament Building and Big Ben, and at night watching England route Croatia, Scotland beat Iceland, and N.Ireland tie with Czech Republic - all at the same sports pub on the same night.

Texas
After 2 weeks relaxing with the family in Denton, seeing Dave play good Cuban music and eating great home cooked food, I’ve started my next small adventure. I’m sitting in a café in San Antonio, and have been hanging out with my old friends from college and med school. They’re all grown up. Chuy has joined a private family medicine practice and is talking about getting engaged, Xav is working toward finishing his radiology residency and just got engaged, and Tony is a successful ER doc and living the good life with his lovely family. Tomorrow I head West, planning stops in Las Cruces, Phoenix, LA, San Jose, Santa Rosa, Honduras and El Salvador, and a few other places before I return to Denton for Thanksgiving, Lord willing. It’s been a good year. And if these few weeks back are any indication, I think another good one is just starting.

April, May, and June

It’s been a long time since posting to the blog, but I’m still here. I've been in Lesotho for about 9 1/2 months, and I have 2 1/2 more months to go before returning to the States. As I haven't written for a while, most of the events I'm writing about in this blog entry are now foggy in my memory (I'm getting old; see below for details). So I’ll just do a short recap (which will also appease the “I haven’t read your blog since your entries are so long” group). You’ll notice few pictures this time around as my camera wasn’t working, but it’s doing better now.

Jeff’s 30th Birthday Party (Saturday April 26th)

I entered a new decade on April 28th. To continue the very short trend of themed birthday parties (last year was the “uniparty” – no details to be disclosed on this website), we chose a Shoprite theme. Guests could wear anything they wanted as long as it was purchased at the local supermarket (picture Safeway or H.E.B, not Super Walmart). There were some very innovative and even attractive outfits – from gift wrapping paper, suitcases, shower curtains, to blankets, plastic bags, toilet paper and cling wrap – to name a few. I’m not sure if I should post any pictures from this night, but I wanted to give a shot-out to my man Jerry, seen here with the bag warrior princess, Kara DuBray.

10th trip to Mokhotlong (April 28th through May 2nd)

As Monday was my birthday, Baylor and the Kingdom of Lesotho decided to celebrate by holding a ground-breaking ceremony for the new satellite clinics to be built around the country. It was a grand affair, with the Right Honorable Prime Minister Mosisili as well as Mark Kline and a lot of the BIPAI team from Houston attending the ceremony. I drove up to Mokhotlong in time to do no work, but I was at least able to share a few cold ones with the local docs – a few from Zimbabwe and a few from Cuba, as well as my good friends Dan the Dual Citizen and Dutch Elise of UNICEF. Overall, it was more of the same business in the mountains. I was a little worried that it would be bitterly cold as we were in Fall and getting close to Winter, but the weather was great the whole week. There had been a large snow storm the week before – the day after it hit the taxis were taking 7 hours to travel what normally takes 2 hours.

Maseru (May 3rd through May 25th)

I worked at the clinic most days, seeing patients, training nurses, and grinding my teeth over patients that weren’t taking their HIV meds correctly. It is so hard to take any medicine in the best of circumstances. But when you don’t have money to get to the clinic, your husband throws away your and your child’s meds because he doesn’t believe in them, or a flooded river has kept you from getting your refills it gets a lot harder. The amount of viral resistance brewing out there due to inadequate adherence is daunting.

11th Trip to Mokhotlong (May 26th through May 30th)

I went up with visiting 3rd year UCSF peds resident and budding pedi ER fellow Kajal Khanna. About an hour into the trip we saw that the distant peaks we were to drive through were oddly white. We got to the first mountain pass and met first ice then snow blanketing the road and surrounding mountains. The drive was slow going, but we didn’t have to turn back – even though a few minutes of minimal visibility and 6 inches of snow on the road made me think about it a few times. The trip was good overall, working in the rural clinics as usual, but this time with a resident who could

carry things for me (just kidding, Kajal; mostly). Thursday in the dark we managed to find the Sani Top Chalet, a nice B & B further east of Mokhotlong town and overlooking the border town at Kwazulu Natal, South Africa. Most importantly, it has the highest pub in Africa – allowing me to obtain the much coveted award for both climbing to the highest point in Africa (Kilimanjaro) and drinking a beer at the highest pub in Africa. Autograph signing to be held at a later date. Friday night we made it back to Maseru to join Anu for our last happy hour together at the Lesotho Sun. I took off the next day on vacation, and he would be gone before I returned. Anu, dude, we miss you here already. Safe travels and rock on with your bad self in your pedi heme-onc fellowship. I'll see you in the Bay Area. [The picture featured above was taken by Anu in Thaba Tseka, which gives you an idea of what Mokhotlong looked like].

Vacation to The Good Old United States of America (May 31st through June 15th)

Along with my brother and sister-in-law, I surprised my mom by showing up to the house unannounced. Thankfully they hadn’t changed the locks (or adopted another child). With 4 nights in Corpus and about 8 in Santa Rosa, I enjoyed all the things I had been missing. We shared good microbrews (Belgian ales in particular), ate good pizza, watched movies, enjoyed great hot weather, ran and biked by the beach (a particularly nice run in Corpus after dawn with the dolphins surfacing in the Bay), ran and biked in some of my favorite California state parks, visited some wineries [saw Wilson winery out in Dry Creek (Sonoma County) for the first time where my friend Dawn is working - what nice zins they have], listened to outdoor music, and slept in my old room. By far the best times were spent just hanging out with my family and friends, especially the group from residency. Traveling in India, Dubai, South Africa, Swaziland, Mozambique, and Tanzania was great, but it was good to be reminded about the true blessings of home, family and friends. To my graduating friends from Santa Rosa, congratulations on finishing 3 years of grueling work (well, not counting Thursdays - except Team Meetings). I love you very much and will see you soon.

Flying Around with Mission Avian Fellowship and Bristol-Myers Squibb

I had the pleasure of hanging out with Tim Vennell from MAF. Tim, his wife and his kids (one boy and 4 girls at last count) have been in Lesotho for about 5 years. He and his fellow pilots fly docs, patients, and supplies around Lesotho in Cessna planes, providing an invaluable service to the Basotho. We traveled with Elliott Sigal, MD, PhD (Executive Vice President, Chief Scientific Officer, President of Research and Development at BMS), John Damonti (president of the BMS Foundation) and Charlotte (a BMS photographer) on a quick tour of the Mokhotlong hospital and one of the rural health centers (Tlanyaku). I was floored when we made the trip that takes me over 4 hours by car in 45 minutes. The health center we visited is 2 to3 hours from the hospital by car, but it took us a mere 8 minutes by plane. Besides being just a little deaf and nauseated (4 flights in 3 hours), I had a good time.

Thats it for now. I'll try to update the blog every 2 to 4 weeks until leaving in September. Hope you are all well,

Jeff

Cape Town and 9th Trip to Mokhotlong

Cape Town and Stellenbosch

We flew out to Cape Town for a long Easter weekend. The trip was great. We stayed in South African wine country, enjoying good wine, cheese, chocolate, and breath taking panoramas. It was so similar to being back in Sonoma County. Similarly Cape Town proper was very reminiscent of San Francisco in so many ways. Located on the ocean, surrounded by fog laden hills, with a vibrant gay population and happening night life, this trip made me feel like I was back in the Bay Area.

Interim Week in Maseru

That was a routine week at the COE. We’re still seeing lots of patients a day, trying hard to finish before dusk some days. Not too much to report.

Back to Mokhotlong

Another week of outreach in the mountains of Mokhotlong. I drove 900 km, much over unpaved roads, and visited 5 rural health centers this week. Mornings are still consisting of rounding with the docs in the children’s ward. The patients on the ward mostly are fighting pulmonary infections and malnutrition. Additionally, an adolescent with meningitis not responding to antibiotic treatment was being transferred to Queen Elizabeth 2 hospital, and another young boy was in traction for a displaced femoral shaft fracture. Most days I returned with a patient for admission: a man with wasting and likely TB, a woman with likely TB whose child recently passed from TB meningitis, and another man with wasting and intractable hiccups for the last 3 months. I had to read about this condition, which has over 100 causes, from central nervous system syphilis to toxic-metabolic causes to phrenic nerve irritation. The drive back was gorgeous. Fall is here, and the hills are starting to dry up a little bit, bringing red grass to contrast the green shrubs on the hillside. More beautiful yet are the pink, violet and white wild flowers that dominate much of the midlands and some of the highlands. The weekend was spent in celebration of Susie’s (Kick For Life) and Kameko’s (Clinton Foundation) birthdays. Anu is getting ready to celebrate his birthday alone in Thaba Tseka on outreach this week L as am I in 3 weeks when I go back to Mokhotlong for my 10th trip. More stories to come!

Take care,

Jeff

March Madness

A Few Interesting Points From The CIA World Fact Book

https://www.cia.gov/library/publications/the-world-factbook/geos/lt.html

Average life expectancy at birth
US: 78 years
Lesotho: 39.9 years

Lifetime risk of maternal death
Sierra Leone: 1/6
NW Europe: 1/30,000

Countries with the highest HIV prevalence (% of the population living with HIV)
Swaziland 38.8% (1st)
Botswana 37.3% (2nd)
Lesotho 29.8% (3rd)
USA 0.6% (71st)

Equatorial Guinea
Only African country with Spanish as one of its official languages
12th highest GDP per capita in the world (Luxemburg is 1st, US is 9th)
But most of the people live on less than a dollar a day, since all of the money (oil) is in the hands of the politicians

A Hard Week At The Baylor Center of Excellence (COE)

The COE is getting busy. We are seeing over a hundred patients every day, with several newly diagnosed kids and adults per day. The new kids are always our sickest ones, as I’ve mentioned in prior blog entries. Several of them have been losing weight, and suffering from fevers, cough, diarrhea and malnutrition for months before they are brought in – frequently by their grandmothers, as the mother has recently passed away. They often come in with skin stretched on bone, with so little muscle and fat. They are basically on Death’s door. We work hard, giving them strong antibiotics and oral rehydration solutions specially formulated for severely malnourished children. We battle over starting and restarting IVs for the administration of the medicines and for emergency fluid replacement when they go into shock. Anu admitted 4 of these very sick children on Monday, and I admitted 3 children on Tuesday, most of which sadly have passed away. Later in the week a woman came in and spontaneously went into labor in the blood drawing room, delivering a stillborn fetus that had probably stopped living a week before. The next day I found myself on a panel that is in charge of writing Lesotho’s national prevention of mother to child transmission of HIV guidelines. It is an unfair world where a recent residency graduate plays a big part in making these kinds of decisions for an entire country. During the week we saw some kids that were incompletely or inappropriately managed at outside hospitals dumped off at our clinic, hoping for better care and more resources. I saw my first case of ophthalmia neonatorum, an experience I won’t forget. Seema was seeing this newborn in the exam room next to mine. The child was born at home and started having eye discharge during the first week of life. After about a week of eye goop, the mother finally brings the baby to our clinic. She has a rag that she’s been using about once a minute to wipe pus off of the closed eyes. I went to better examine the eyes, and while trying to open the lids a thimble full of pus came out from under the lids. The lids were so swollen I couldn’t open them. I was amazed, others were shocked, the mom wasn’t impressed. No one fainted. Those of us that see kids in the office have met a hundred new moms who come saying that their baby has “eye discharge”. The med student or resident in training needs to know how to differentiate harmless eye discharge from true ophthalmia neonatorum. There is no confusing what I saw that day for harmless eye discharge. If all of the new moms of the world could see what I saw, none of them would ask if the scant eye boogers that they have to wipe off in the morning once in awhile were dangerous eye discharge. Seema treated the child with ceftriaxone and erythromycin, treated the Mom, and asked for the dad to come in. That’s because the pus coming out of the baby’s eyes was likely caused by infection from gonorrhea (and probably also chlamydia) – transmitted to the child while traveling down the birth canal. Yes. Gonorrhea of the eyes. I’ve never seen this in the States, due mostly to the fact that most newborns get preventative eye medicine at birth (and partly due to a lower rate of gonorrhea in the US). While reading up on eye medicine for the newborn, I found a study in Kenya showing that iodine eye drops not only are cheaper than the meds we use in most of the world, they worked better and were less irritating. This study was done 13 years ago! My best guess why we haven’t changed to iodine drops is that Big Pharma (the pharmaceutical industry) can’t market cheap iodine and prefers us to use their expensive meds. Gotta love Big Pharma.

A Louse In The House?

Kara (fellow PAC doc and one of my two roommates) found a very small bug on her back when she was changing her shirt. She squashed it, and realized that it was full of her blood. We all took a close look, and voted that she most likely had body lice picked up from a patient at clinic. We also by a non-unanimous decision voted her off the island. I kept the squashed bug in a piece of clear tape and looked at it under the microscope at work the next day. Upon closer look under the scope, we saw a creature of uncertain identity but one that did not resemble a body (or other) louse. That night I woke up because I felt something crawling on my foot. I’m a vegetarian and don’t like to kill things, but I occasionally make exceptions for evil creatures I find in my bed. I caught the thing and squashed it. In the morning I opened UpToDate (a medical resource on the computer) and on a hunch opened the article on bed bugs. Yep. I was right. The thing I found crawling on my foot was a dead ringer for the bed bug featured in the article. What in the world? I’m not a particularly dirty guy. The sheets get washed, I bathe fairly frequently, I don’t wear clothes I find in alleys. We have a really clean, modern house. There are no thatched roofs or mud floors here. Going into crime scene investigator mode, I found another 2 that night, losing one on the floor in the living room (much to my roommates’ dismay). I quickly learned a lot about bed bugs. Bed bugs are a little gross. They suck your blood. They can live for a year. They are found in dirty homes but also well-kept abodes. They have a sweetish smell when squashed (like a South Texas stink bug). They come out of cracks and crevices at night, attracted by your body heat and carbon dioxide, and they feed on you while you sleep. They are associated with areas where birds and bats roost, and they can live for a loooong time without a blood meal. I bombed my room with FumaTab, something I bought at the store that has more health warnings on the label than a nuclear bomb and behaves like a ninja smoke bomb when lit. I quarantined myself to the couch (again to Anu’s and Kara’s dismay). I slept there for 7 days as the smell of the Fumatab’s carcinogens slowly cleared. One day I came back from a run, and Anu said to me, quite seriously, “You’re going to have to stop sleeping on the couch. Because Kara is going to start sleeping on the couch”. She showed me her bed, which was totally infested. Of course that meant that it wasn’t a louse on her the week before - it was a baby bed bug, a nymph, if you will. So now, about 3 FumaTabs and a can of Doom insect spray later, we seem to be bed bug free. We’re both back in our own beds, and Anu’s room, somehow, still seems to be bed bug naive. Apparently they prefer Mexican food and California cuisine to Indian food. Hopefully they aren’t in our couch. Hopefully they aren’t looking over my shoulder while I write this about them. They might get upset. Unfortunately, the chance is moderately high that they’ll surface again. Then we’ll call the exterminator. If that doesn’t work, we’ll get new beds. If that doesn’t work, I might come back to the US. Or better yet, Antarctica. They don’t do particularly well on icebergs. See attached NYT article.

http://www.nytimes.com/2006/10/15/realestate/15cov.html?pagewanted=1&_r=2

8th Trip to Mokhotlong

It was good trip. I came in on Sunday night, having made the beautiful 4 hour drive without incident and arrived at the Touching Tiny Lives orphanage in Mokhotlong proper where I’ve been staying. This has been a cool place to stay. I get to hang out with Dan and Mo, two North Americans who have been working here for several months. They are fun to hang out with, and coincidentally happen to be good cooks. The orphanage is well funded from the US, so they have hot running water, electricity and dial-up internet.

I spent the week in the typical fashion: rounding with the local docs on some of the inpatients, driving to rural health clinics in the mountains, mentoring nurses on the care of HIV positive and negative patients. The weather has been great; it’s starting to rain less but isn’t terribly cold at night. It’ll start snowing here in May or June.

I saw a variety of patients during the week: HIV positive adults with lung cavitations caused by tuberculosis, sick and healthy HIV positive kids and pregnant women, a term pregnant woman with 5 days of a big swollen tender leg, likely caused by a blood clot that could break off and float to her lungs - possibly killing her (there’s no access to PTT monitoring at that hospital, and at times nowhere in the country. We started her on subcutaneous unfractionated heparin and flew her to the capital). There was a young boy with a Colles’ fracture, an impressive case of pruritc papular eruption, a 12 fingered baby, severe nipple eczema, hydranencephaly with hydrocephalus, and a 2nd case of ophthalmia neonatorum. This one had been “treated” by a nurse assistant a few days earlier with chloramphenicol eye drops and trimethoprim/sulfamethoxazole. We started the right drugs and think the baby will be fine (the infection, when left untreated, can cause blindness).


Back At The COE

Work in Africa has brought a mixture of strong emotions. You’ll find a family slowly wasting away due to lack of money, education, and power. The man of the house just won’t let them test for HIV until it’s too late. Then you’ll see a new mom who did everything right from the beginning – like the woman who I met in the first trimester when I had just arrived in Lesotho – and the newborn baby’s test shows that he is HIV free. Both instances affect your soul.


Lesotho’s First 80s Party of 2008

So the 80s was an interesting time. I was reminded of this decade of my life as I found myself “pegging” (aka, “tight rolling”) my jeans, putting on clothes that didn’t match, and creating my mohawk for the 80’s party on Saturday night. A


mid the sounds of Toto, Bon Jovi and Journey, we enjoyed a bit of caipirinhas, drinking games, and dancing. There isn’t much more I can say about the party. Is there really much more to say about 80s parties? Let the pictures do the talking.

News From The Farm

By brother David and his wife Jessica just celebrated their 6th anniversary together. Dave, I owe you a twenty. Just kidding. I’m very excited to think about spending some time together with you guys when I get back home, and maybe we’ll even get a chance to meet up off the continent before then. I love you.

I’m excited to say that my mom is enjoying her first weeks of retirement. She put in a ton of years at Del Mar College in Corpus Christi, Texas, and they are missing her already. I can’t remember life before coming to see Mom at the office, hearing her laughter from down the hall, and selling Christmas wrapping paper and chocolates to the nice ladies and gents in the office. I want to send a big hello to all at the Registrar’s Office that read the blog – your support has kept mom sane (relatively) and helps me all the way out here as well. Thank you.

Happy Moshoeshoe’s Day,









Jeff

Tanzania and the Seventh Trip to Mokhotlong

Anu and I headed out early on Friday morning to start our 2 weeks of vacation (the PAC treats us well, we get 22 days of vacation per year). After a rough start (one of our tires has a slow leak and was almost flat in the morning; oh, and the car wouldn’t start), we made the 3.5 hr drive to Joberg pretty uneventfully. Our friends recommended this great economy airport parking for a whopping $1.25 US per day. We had our tall Castel Lager on tap at our favorite airport restaurant (it was after noon somewhere in the world) and caught our flight from Joberg to Arusha via Dar Es Salaam and Zanzibar, where we stayed at the Outpost Lodge under torn mosquito netting (malaria prophylaxis: I was on doxy, Anu was on prayers).

Saturday morning, after a brief breakfast sprinkled with E. coli (as Anu would find out later), we met our driver and cook, Marco and Abdullah, and headed off on safari. We spent the next few days seeing tons of animals in famed sites such as Lake Manyara, Ngorongoro Crater, and the Serengeti. Yes, The Serengeti. I had to repeat that to myself several times during the trip. This huge area of plains, acacia trees, and heards of thousands of grazers was something just seen on the Discovery Channel and not something that I'd ever go to. Of the three sites, Ngorongoro was perhaps the most beautiful. As we descended in our 4x4 early Sunday morning, Anu and I felt like we were driving through the Garden of Eden. Vibrantly garbed Maasai herders were the only humans moving through this huge area inhabited by thousands of animals. The animal density here was amazing. Every where you looked, animals grazed, ran, and rested, giving little care to the various Land Rovers that crawled over the landscape. Over the four days of safari through Lake Manyara, Ngorongoro and the Serengeti, we saw herds of zebra and wildebeest, over 30 lions, water buffalo, hippos, leopards, cheetah, flamingos, cranes, hyena, you name it (well, no rhino, but we had seen some great ones back at Kruger Park). One early morning in the Serengeti we awoke to find a pack of elephants walking through our campsite. We were very glad that they were in a good mood.

Though the camp food was impressive (items of note: vegetarian quiche and creme brulee), we were glad to get back to civilization where we were able to eat an amazing dinner at Onsea House. We met gourmet Flemmish chef, Axel, who prepared one of the two best meals I’ve had in

Africa (the second one was also made by him, one week later) – a 5 course meal of vegetarian fair paired perfectly with choice African wine. We joined Heather Crouse, pediatric ER fellow and friend who came in from Houston a few days before we got back from safari.

Mt. Kilimanjaro

We needed that great meal, as the next morning we started our trek to Mt. Kilimanjaro, the highest mountain in all of Africa. We were greeted at our hotel in the morning by our team – enough guides, assistant guides, porters and cooks to make a few soccer teams (19 in all). Climbing the mountain was an interesting, if not fun, experience. The hiking wasn’t impossible, but it was no cake walk. The scenery was not beautiful, but definitely exotic – more like a science fiction writer’s depiction of a planet in another solar system. The camp food was getting a bit repetitive by now, and sleeping in a small tent with Anu after not bathing for several days was getting a little difficult (I have no idea how he smelled, I couldn’t make it past my own foulness). The outhouses were pit latrines where you basically tried to do your business through a hole cut in the floor without getting anything on your feet. Somehow I managed to not use a single squat toilet in all of southern India but was forced to learn here, where my quads were often shaking from the strain of the day’s hike. I could go on and on about the woes of eliminating on Mt. Kili, but I’ll spare you the details. Flora was scarce, and Fauna more so – mostly four-striped mice that tried to get into your tent and ubergrande crows that would probably go for your eyes if you didn’t make it successfully to your campsite in time. We discovered first hand that in addition to worrying about mountain illnesses such as AMS (acute mountain sickness), HAPE (high altitude pulmonary edema) and HACE (high altitude cerebral edema), perhaps the most troublesome if not most dangerous form of these diseases was HAFE (high altitude flatulent explosions). I had heard of this entity but felt that it was most likely a myth made up by mountaineers to keep weaker people off their mountains. Let me tell you. It is a reality.
We began our trek to the summit a little before midnight. It was cold, real cold. The headlamps accented the glittering ice on our tents as we began our ascent. Aside from the temperature, we were blessed with great weather. The wind was low and the rains from the day before had stopped. We were greated by heavenly stars, an orange moonrise and the glittering lights of Moshi city so far down that you felt like you were in a plane. The climb took us from around 4,600 meters at campsite to the peak at around 5,800 meters. During the hike, climbers experienced symptoms from mild headaches and nausea all the way to vomiting, confusion, and loss of balance. I was pretty lucky. The last couple hundred meters were pretty tough. As I wondering if any of my toes would be frostbit and was nauseated and really tired, I had this great image of all of my family and friends watching me as I was climbing. Anu says it was due to hypoxia, but I had a huge endorphin rush from imagining all my family and good friends from Texas and Santa Rosa right there with me, cheering me on, giving me the support I needed to get to the top. So, to all my family and friends out there, thank you. I don’t know if I could have done it without you.

We made it to the summit right before sunrise. Our guides gave us chocolate bars and sang local songs that sounded like prayers of thanks to the mountain gods. The top is all snow and glacier, beautiful, breath taking, and very cold. You certainly don’t feel like you are in equatorial Africa. I took some good pictures with Heather’s fancy camera, and some OK ones with my own basic digital cam (those included here). What a feeling of accomplishment. What a feeling of, thank God I never have to do that or anything like it again.
The descent was long and hard on the knees, but it was great to sleep at a better altitude. The shower back at our hotel was wonderful; I probably lost a kilo of dirt. We had our second great dinner and then flew off early the next morning to Zanzibar, an island off the coast of Tanzania. We stayed at Fumba Lodge, a picturesque beach resort where I read The Time Traveler’s Wife, ate great food, and watched the ancient Moorish dhows sail by. Beach time with nothing on the agenda was exactly what I needed after the mountain. I'll add some photos later; my camera was out of batteries by this time. I’m thankful for Heather for doing so much of the ground work for this trip. She was a good traveling partner and put up with my complaining and eccentricities. I’m also thankful for Anu, who I’ve traveled with to more countries than any other person (10), and who continues to still be a comrade even after all of that.

Mokhotlong (Seventh Trip)

After a whopping 2.5 hours of sleep the night we returned from Tanzania, I woke up early and headed off to Mokhotlong for outreach work. As usual, it was, as my friend put it, a mixture of successes and frustrations. The health providers are getting more comfortable with the management of children with HIV, antiretrovirals are being distributed more widely, and more people are testing so they know their HIV status. Frustrations included seeing advanced disease that should have been treated months or years ago (a child with a case of Potts disease – TB of the spine that causes disfiguration and sometimes paralysis, seen in a 6 year old orphan), continued stigma (an entire family present in clinic, both parents looking thin, an adolescent child with signs of HIV infection – diffuse lymphadenopathy and bilateral parotid enlargement, and their brand new baby; no matter what we said about the benefits of testing and treatment, the father was deathly afraid of knowing his status and wouldn’t let us test him or any of his family members), and poor access to care (a first time mother presenting at the end of clinic with her one month old baby that had a blueberry muffin type rash for a week and was in status epilepticus; we were at a rural health clinic in the mountains, the anti-seizure medication was expired by 8 months, and there was no oxygen or breathing mask available; we made the drive back to the hospital in record time, started emergency measures and the child made it through the night, though his prognosis is grim). I’m back in Maseru now, and I’ve spent the weekend being a veg around the house, catching up on some much needed bumming around.

Hope you are all doing well,

Jeff

Finishing at QE2 and The 6th Trip to Mokhotlong

QE2 Winds Down

The last 5 days at the Queen Elizabeth 2 (QE2) Children’s Medical Ward (CMW) were, unsurprisingly, not easy. My patient load was certainly manageable. Unfortunately, this was due to both discharged patients (yay!) and children that had died. Looking back, I certainly worked harder during most of residency rotations. The reason that I was so burned out after only 2 weeks of QE2 (which doesn’t even involve being on-call) was due mostly to a combination of preventable deaths, lack of supplies and an apathetic staff. I passed off the baton to Anu, my roommate who helped me during my rotation at QE2 both by giving advice on how to manage the patients and offering moral support. I felt bad passing the work to him, as he had already, in a way, gone through the rotation with me. It was interesting to see him react similarly to me as his time at QE2 progressed. The frustration settles in, you begin to question your skills as a doctor, and you start to feel like Death himself, roaming the ward in a black cloak holding his scythe.

Whew. That was a bit dark. Glad that’s over. I’ll probably do one more rotation on the CMW closer to August.

Mokhotlong

After a great weekend of sleeping in (and not having to go in to QE2), I drove out to Mokhotlong, along with Ntate Thuso, a local counselor, seen in the pic (I'm on the right). Though the work in outreach is always exhausting, I felt great to get out into the countryside and travel among the sheep under the open sky. The routine was the same: mentor docs and nurses both in the hospital and the more rural health centers, distribute medications, and see a few patients on my own. Probably my favorite encounter of the trip was diagnosing a woman as pregnant, about half a year after her tubal ligation surgery. I was able to show the local physician how to do an early pregnancy ultrasound (thanks to many days in OB intake and on therapeutic abortion rotations) and prove that it wasn’t an ectopic pregnancy. Overall, I felt that things in Mokhotlong were slowly moving in the right direction. The health centers seem to be on the verge of getting their own supply of meds, the nurses are getting more adept at seeing HIV positive patients, and Riders for Health (http://www.riders.org/) are supplying some motorcycles to be used by the health system, to name a few advancements.

Maseru

Back at home base, we celebrated by watching the entire Lord Of The Rings trilogy over Friday, Saturday, and Sunday. Anu gets the prize for Most Dedicated Hobbit by lasting the entire extended version of the Two Towers (until 3:45AM) and then going in the next morning to QE2 to round on the entire ward. Work this week at the clinic has been steady and routine. I’m seeing a mixture of healthy HIV positive pregnant women, children on long term anti HIV therapy, newly diagnosed HIV positive adults, and some really, really sick kids (most of which were recently diagnosed with HIV). Most of these sick kids we try not to admit, since the conditions at QE2 are so atrocious and what can be done for the patients therapeutically is so limited. Today I admitted another child to QE2 with vomiting, diarrhea, malnutrition, and possible sepsis. Yesterday the child looked relatively healthy, with what I though was just going to be a case of viral gastroenteritis. Some of these kids can get sick so quickly. I don’t think the child will survive. Today, I’m kicking myself for not admitting the child yesterday. You just never know. In similar fashion, I’m managing a severely malnourished child with possible meningitis as an outpatient! This would never happen in the States. Medicine is very different here.

Kilimanjaro

Friday Anu and I’ll be flying out to Tanzania for two weeks of glorious vacation. The plan is to go on safari in the Serengeti, see famed Ngorongoro crater, climb Mt. Kilimanjaro, then relax on the beaches of Zanzibar. And while it might seem to my friends (Dolan, et al) that I’m not actually working but only vacationing in Africa, I must remind them that I blog mostly about my vacations while sparing you most of the details of the day to day work life here, therefore causing the aforementioned confusion.

Your's truly,

Wolverine