Pierce In Africa

And Finally...

2008-11-12T18:09:00.000-08:00

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

2008-06-17T14:27:00.000-07:00

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

2008-04-06T15:05:00.000-07:00

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

2008-03-11T10:30:00.001-07:00

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

2008-02-10T05:36:00.000-08:00

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 taki ng, 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

2008-01-16T12:45:00.000-08:00

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

2007-12-29T13:19:00.000-08:00

Queen Elizabeth 2 Government Hospital

Wednesday, December 19, 2007

Today was my first day as pediatric AIDS corps (PAC) doc assigned to the Children’s Medical Ward (CMW) at QE2. I can already tell that these are likely to be two of my most trying and memorable weeks during my assignment in Lesotho (though I think I get to do this again in 2008). This morning I met with Dr. Guada Richter, PAC pediatrician who was finishing her two weeks on the CMW. We rounded on the current list of patients that the Baylor docs are in charge of. Malnutrition, tuberculous meningitis, bacterial pneumonia, pleural effusion with shifted mediastinum, bacterial meningitis, impressive hepatomegaly, and gastrointestinal bleeding were some of the “run of the mill” diagnoses. Queen2 is rich in contrasts. It affords a wonderful teaching opportunity. The variety of diseases seen, the autonomy it provides (think of the opposite of inpatient peds at Sutter – when it used to have inpatient peds), the procedures – all bring amazing learning opportunities. I started my first scalp vein IV catheter on a baby that had poor peripheral venous access. I have no attending. More unbelievably, I’m the “private” referral doctor in charge of patients on the CMW of the national referral hospital. Yes, it’s ridiculous. I’m way out of my league.

I was rounding in the nursery, a small oven of a room with babies stacked in neat little rows lining the room – tiny premature babies, babies with communicable infections, all lined up next to each other in their cribs. It really catches your attention the first time you see a roach scurrying up the wall next to a row of cribs. I asked why my 20 day old baby with suspected meningitis hadn’t had his temperature recorded (this is normally done only once a day in the nursery at QE2).
“The thermometer (mercury) is broken”.
“OK, could you borrow one from the busy maternity unit next door (I’m sure it has hundreds of deliveries per month)”
“No, they don’t have one either”.
What? Wow. It turns out they can only get one from the pharmacy on Fridays and Mondays. Oh. I see.
Back at the CMW, I was starting an IV on a child on one of the two exam tables in the treatment room and looked over at a small, still form. A 4 month old child was covered with a sheet, left alone on the exam table. My first thought, Why is there a dead child on the procedure room exam table? Where is the mother? Why are the same tables that are used for lumbar punctures and initiating IVs also used for holding the deceased children? Why do children die on the ward almost daily? The child had been seen in the Casualty Department, our version of an emergency room and admitted to the CMW. While the child was waiting in his mother’s arms on the bench to see the admitting medical officer, the child died. No Code Blue called, no rush of doctors and nurses to bring the child back from the clutches of Death. Just a child that presented too late to the doctor due to a hundred reasons. I quickly (and coldly?) thought to myself, move on, keep working on your list of patients to save the ones that you still can.

Day 2

Really the morning of day 3 before work; I was too tired and depressed to write last night. Yesterday was a tough day. Rounding on patients throughout the day, catching up on things that needed to be done to the patients I was getting to know, admitting new patients, doing procedures. Blood that needed to be hung over night and wasn’t, meds that should have been given but weren’t. Kids in respiratory distress with only a weak hint of oxygen piping through tubing from an oxygen concentrator split between 3 kids. No ventilator for kids in respiratory failure. Bad attitude from nurses (How much can I blame them? They have too many patients, they see death all the time, and they get paid $8,000 a year). Still no thermometer in the NICU. A patient trying to kill a roach on the wall with her shoe. I expect at least a few kids to be dead this morning. Most of the deaths would be preventable in the States. Man, I’m already getting depressed.

The Weekend

Weekend rounding went more smoothly. I was able to see the patients and get out into the fresh air by midday. Going for runs, reading a book, trying to learn the guitar – all keep the sanity in my life during this tough rotation.

Holiday

Christmas Eve at the CMW was tough. Patients are often kept two to three in a single bed due to overcrowding. I was rounding on one of my patients (a child that had seized for an hour at home because the mother didn't have money for a taxi ride to the hospital - the fair was 50 cents) when the mother of the child sharing the bed started wailing. The translator told me she was crying because her child just died. What? I called for the other doctor, and we brought the child into the procedure room and started resuscitation. The attempt was futile. The heart had already stopped. There was no support staff. The was little equipment. The child had gastroenteritis and likely bacterial sepsis and died from cardiopulmonary arrest, due possibly to aspiration or electrolyte imbalance. There was nothing we could do.

Coming home that afternoon, I decided to go with my friends to the Drakensburg mountains for Christmas. This expansive mountain range runs through Lesotho and South Africa (SA), and we visited a resort in the central Draks located east of Lesotho in SA. We camped on Christmas Eve in a light, mesmerizing drizzle that soothed my hospital pains, and I stayed in a swank room the following night. Christmas dinner was OK, but it sure didn’t compare to the feasts at the Pierce house in Corpus. I thankfully was able to talk to the family as they opened presents and sipped on their morning coffee. Wednesday I was off from work for Boxing Day, a holiday that reportedly has nothing to do with fighting or underpants (though there is Dad in his undershirt; caught with my webcam!). We had a leisurely drive back to Maseru, stopping once again in Clarens for a little microbrewery reward, in celebration of Boxing Day, of course.

Back For More

Back from the beautiful Drakensburg mountains, I awoke Thursday morning with the intent of a run. The days can be long at QE2, so I like the idea of running before work. Unfortunately, the bed gravitational pull (BGP) was again too strong (perhaps the 3rd failed attempt so far while on the QE2 rotation). On the way to work, I was expecting the worst. I felt pretty sure that there would be at least a few of my patients that had passed away over the holiday. Believe it or not, all of the patients that I was in charge of were alive. In fact, most of them were getting better without me. It made me wonder if I should try coming to work every 3rd day more often. I was able to move all of the “sick” patients out of the acute room and into rooms where the more stable patients stay. I also discharged a number home. I am amazed how the reaction to the news of leaving the hospital is universal: giddiness, smiling, even occasionally dancing. I guess most people aren’t happy in the hospital. I suppose that includes me as well.

Note: Roach count today - 2 in the nursery, only 1 on the children’s ward.

While I was seeing my patients another child with advanced diarrhea died. Eerily similar to Christmas Eve, I was rounding on my patients when a mother started wailing. Resuscitation attempts were again futile. This time I realized that we do have some suction available. It is a plastic looking contraption that you have to pump with your foot to create a weak suction. This “code blue” and aftermath were so starkly different from similar events in the US. A nurse would briefly come in the room and then leave. It’s as if they have no training in resuscitation, almost as if they are afraid to be involved. The medical officers found the medications, and drew them up in syringes; there was no one from lab (“stat labs” mean within the same day), no one from x-ray (no portable x-ray device that I’ve seen), no intensive care expert from the ICU to lend a hand (no Jim Gude or Ken Lamb; no Bombers). Just fumbling with worn down equipment, expiring medications, and apathetic staff. The environment in the acute room where the child had been staying was also sad and intriguing. The mother was not taken from the acute room after the death (though I offered; there is no “quiet room” for families of the deceased); instead she stayed there, crying while the other mothers fed their babies, changed their diapers, and joked about various things. Though childhood death is so common here, there seemed to be no camaraderie among the mothers (I expect this had something to do with her being new to the ward). The doc who had seen the baby in the morning didn’t stop rounding on her other patients, so I did what I could to help console the mother.

For a further look at QE2 in the news:

CNN online special that mentions Queen Elizabeth 2 hospital (check out: http://edition.cnn.com/video/#/video/international/2007/12/05/inside.africa.hope.for.aids.orphans.cnn?iref=videosearch)
You can also see the recent (though fairly inaccurate) LA Chronicle article on Queen 2 and Bill Gates funding (see: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/12/16/MNJFTVFK3.DTL).

Friday and Saturday

I’ve been getting more into the swing of things. There have been several days without an admission, there have been fewer IVs to struggle with (I’ve become best friends with IM ceftriaxone), and I’ve had a chance to discharge some patients. Discharge basically comes down to: the patient no longer needs IV meds or oxygen? Ok, pa' la casa - they’ll probably do better at home. I’m sending patients home in worse condition than I would in the States, but with the lack of quality nursing care (there are medication errors every day) and infection control (I’m almost the only staff person that washes his hands) I feel the hospital is a danger zone, a ticking time bomb. We’re working with the medical officers and the nurses, giving suggestions and the occasional lecture, but we’re not in the position to make major changes. I wish we were. Take, for example, the 12 year old girl that has been walking around the entire CMW. She plays with the other children, jokes around with the nurse and the patients’ parents, goes up to the medication cart and receives her meds along with the other patients. She wears a surgical mask. Why, you might ask? She is being treated for pulmonary tuberculosis for the third time and still has TB in her sputum. She most likely has multidrug resistant TB (MDRTB), a form of TB that is very difficult and very expense to cure, even in the US. Her mother doesn’t visit often, so she gets lonely in her “isolation room” with is about the size of a closet – similar to what I imagine solitary confinement cells are like in prisons. The docs and nurses have all tried to keep her in her room but sympathize with her loneliness; she therefore has been allowed to pretty much do as she pleases. I called a meeting of the staff and talked with the child. We made a compromise where she is allowed to be outside in the little playground when she isn’t in her isolation room (TB is very hard to catch when you are in the open air). Also, I bribed her with a cookie. We’ll see how long the deal lasts.

I’ve got 5 more days to go on this rotation. I’ll let you know how it goes.

A story about the Mission Aviation Fellowship that flies docs around in Lesotho just came out in the Houston Chronicle. Our work in Mokhotlong is mentioned in the article; make sure to also click on the audio slideshow. Smiley Pool (photographer and longtime comrade to the PAC and BIPAI) did an awesome job.

http://www.chron.com/disp/story.mpl/life/religion/5408265.html

Take care,

Jeff

Wow, finally!

2007-12-13T15:46:00.000-08:00

Finally, A New Blog Entry!

It’s hard to believe it’s been months since I’ve updated the blog. I’m not sure why it’s taken so long. The work here in Lesotho has become a little more involving, and in addition we seem to be traveling every weekend. I’m not complaining. It keeps us out of trouble, I’m sure. The good news is that we now have high speed internet at the house, so I should get a little better at keeping you informed (I know you’ve been on the edge of your seats). Included in this blog entry are more details and pictures from the outreach work in Mokhotlong, an HIV testing event, weekend trips to South Africa, and my vacation to India.

Second Trip To Mokhotlong
October 21 – October 26

This time the scenic trip up into the Maloti mountains was undertaken by a group of four: Paola Peacock-Villada (Clinton Foundation), Tony Garcia-Prats and Heather Draper (Baylor), and myself. The Clinton Foundation works internationally to obtain more affordable prices for HIV meds and testing supplies. Some of Paola’s work has included increasing testing of HIV positive children under 18 months with the DNA PCR method, improving access to care, insuring good follow up after diagnosis is made, and helping to streamline the labs across the country so that crucial lab monitoring is available. The PAC doctor’s work would be impossible without the hard work put in by the Clinton Foundation.

Again as we headed up the mountains we were greeted by heavy clouds, though this time they only released a light drizzle instead of hail. Though later we rounded a bend and were awed by an expanse of freshly fallen snow! Snow in Africa as spring turns into summer. Amazing.

At the end of that first Monday, I felt like I was already getting more done than my first time in Mokhotlong. I spent more time working with the nurses of the maternal child health clinic and the maternity (labor and delivery) ward. Regardless of overtime or effort, nurses at this hospital earn next to nothing (yes, even Sutter Santa Rosa pays more). There are 5 maternity nurses, one on overnight at a time, pulling 12 hour shifts. There are over 100 deliveries a month, and the nurses, who are all trained as midwives, do just about all of the vaginal deliveries. For the most part during the night shift, the physician on call is just called to perform cesarean sections [and they aren’t even obstetricians…shocking! (said with sarcasm)]. The physicians still write the orders (like inducing with 50 mcg of misoprostol; they only have the 200 mcg tablets so they can only break them down to quarters; though it’s better now…most of their inductions were failing possibly due to expired Cytotec), perform the ultrasounds (I was teaching them how to do 3rd trimester biometrics – measuring various fetal parts to help determine how far along the pregnancy is; thank you Tom Neal), and of course perform operations like tubal ligations, etc. I have heard conflicting information about pregnancy terminations. A doctor in Maseru told me it is a legal procedure, and she does them at her private clinic for roughly $200 dollars (remember that the average income is less than 2 dollars a day here). One of the Zimbabwean docs working in Mokhotlong says he was told that it was illegal (women have been brought to the clinic by police after having an abortion), and it seems no one in this expansive district performs them. Some women go across the border to South Africa to obtain the procedure. I haven’t seen any septic abortions come through the maternity ward, but with access as limited as it is, I won’t be surprised when I do.

One morning I walked onto an interesting scene. I found a lone nurse in the delivery room scrambling to get oxygen and suction started for the struggling baby she just delivered. I took over the resuscitation, while the same nurse returned to the new mom who was lying naked on a rubber sheet that covered a foam “mattress”. Not changing gloves, she took out the needle and thread and started repairing a 2nd degree laceration. She was a little flustered when, wide-eyed and open-mouthed, I asked her if they always did the repairs without local anesthetic. She shuffled around the room looking for lidocaine, found it, then went back to the repair (same gloves on) without using it. Wow, that patient was sooo stoic; she just made faces and a few quiet grunts. Amazing. I didn’t like it; but amazing none the less. Following the repair, the patient put on her dress, picked up the baby, and walked out of the delivery room and over to the communal post partum room. I’m not sure, but I don’t think she had a birth plan.

Soccer with the princes

The PAC docs and the clinic staff helped test and screen kids at an awesome HIV testing event/soccer tournament in Mohale’s Hoek, Lesotho, organized by our friends David, Pete, and Paola. Prince Harry of England and Prince Seeiso of Lesotho, whose charity organization Sentebale (meaning “Forget-Me-Not”) was involved, popped by in their helicopter to watch HIV education and testing practices. See attached pic of the prince with Baylor docs Kathy Ferrer and Edith Mohapi, as well as Paola and Pete. Check out the Sentebale website for more info: http://www.sentebale.org/home/index.html

Arrival of the visiting scholars

I was very happy to see my old UT Pan Am alum and friend Yvette Almendarez and her pediatric colleague Ashley Cox arrive safely in Lesotho. They are both Baylor Med School grads and are in their final year of pediatric residency at Texas Children’s Hospital in Houston. They came to learn a little more about pediatric HIV, help us in the clinic, and see the sights of southern Africa. Mostly they just called John to fix their plumbing and fight off squirrels in the attic at 3 in the morning. But that’s too long of a story for now. We took another day trip to Clarens, the quaint town in South Africa that has good cheese and beer on tap. Sounds strange to travel to another country for cheese and beer, huh? Well, not if you know me. This picture is us in our car on top of a moving tow truck. Read on for more details. Yvette and Ashley are back in Houston now. Thanks for coming guys and good luck; we miss you.

3rd trip to Mokhotlong

Following an interim “routine” week seeing patients in Maseru, I made the trip out to the mountains again, for the first time going it alone. It was slightly romantic, being the lone doc in his 4x4, slowing winding his way up the mountain roads between remote villages, greeting sheep herders and dodging sheep dung. This picture was taken on the way back from Linakaneng. The animal is an nku (sheep; maker of sheep dung). Along with the African docs assigned to Mokhotlong city, I saw children in the children’s medical ward (CMW), adult inpatients, and patients at the dedicated Lerato (meaning “love” in Sesotho) HIV clinic. This is the clinic that is a smidge bigger than a closet, but with fewer resources. I drove out to the rural health centers of Libibing, Linakaneng, Malefiloane and Mapholaneng. The roads are unpaved and super rocky, but wind through gorgeous terrain – one of the best commutes in the world. There is always plenty of variety in the conditions the people have to face (usually more advanced in their course and always with fewer resources available to diagnose and treat them). To name a few, I saw 2 likely new cases of lupus, gestational hypertension, a kid with total body swelling due either to malnutrition or kidney disease, active tuberculosis (so common that it’s routine), and conditions associated with the weakened immune system caused by HIV infection. Every day is different, offering the chance to work in the hospital and outpatient setting, do home visits, deliver lectures, mentor nurses and docs, and perform tough blood draws (including external jugular and femoral vein blood draws on infants).

Reunion in Joberg

Thanks to the planning and hard work of Seema, the medicine/pediatric PAC physician – gourmet chef – vacation planner extraordinaire working with us in Maseru, several of the PAC docs from around southern Africa got together to enjoy museums, food, caipirinhas, dancing, and the occasional irritant gas bomb (random). As Yvette and Ashley will attest (they will, just ask them), the trip from Maseru to Joberg was a bit hectic. While driving the car on the highway Anu realized that the clutch pedal stopped working, and he could no longer change gears. While theoretically we could have completed the remaining 3 hours to Joberg in 5th gear, it was his better judgment that had him pull off to the side of the road. Thanks to our South African car insurance, we were quickly towed to a “24 hour station” manned by some of the toughest looking men (and women) of the Free State (the name of the South African state in which we were stranded). I wish I had a picture, but the leader, a huge Afrikaans guy, had the most impressive mullet I’ve seen in Africa. They were great, and actually worked on the car for about an hour on a Friday at 8pm, eventually replacing a broken seal and getting us on the road (for an amazing $70 US) in time to meet the rest of the group for dinner in the Melville district of Joberg. The picture is not actually of the garage crew but two sexy hunk Botswanan PAC docs - Jonathan Bernheimer and Paul Mullen.

Two weeks in India

I had the pleasure of joining Anu and his parents on a whirlwind trip of southern India. Anu and I flew via Emirates Airlines, leaving on a red-eye from Joberg to Dubai, the capital of the United Arab Emirates (I actually remember learning about that country in Mrs. Putman’s 6th grade Social Studies class) and on to Mumbai (which is not, strangely, the sister city of Dubai, but did used to be called Bombay) on the west coast of India. Anu’s family was truly wonderful, treating me like part of the family from my first moments in the country. This was my first trip to India, and was it ever much anticipated. Since going to med school, where 80% of my friends were 2nd generation Indian-Americans (not to be confused with American Indians, Native Americans…or Pakistanis), I have been in love with what I have learned of the culture. The colorful and flowing saris, the permeating presence of Hinduism, Christianity and Islam, the music, and the food (ahhh, the food) were richer than I had anticipated. I was impressed with how much more crowded it is compared to Africa, especially Lesotho (I imagine much of Nigeria might be more similar to India in this respect). There is little possibility to get away from honking horns, city lights, and jostling crowds – even in the relatively less populated south where we were traveling. Anu’s parents, originally from India and currently living in Midland, TX, set a busy but enjoyable pace. We took several night trains, and I experienced first hand the difficulty of voiding on a bumping Indian train. I also saw more rats (Anu insisted they were just mice) among the tracks one night than I might have seen in all my life. Just imagine that scene from “Indian Jones And The Last Crusade”, then imagine world peace. Well, why not, you were already imagining, weren’t you? We traveled through 6 states: Maharashtra, Goa, Karnataka, Kerala, Tamil Nadu and Andhra Pradesh, went to a family wedding at the Tirupati temple (so much gold and sooo crowded), hung out at a hill station in Coonoor, and motored and slept on a house boat in Kochi. By far the most amazing experiences were the meals. I had so much masala dosa,
idli, vada, chapatti, sweet lassi...and thank goodness, never got sick...as far as I know. Well, I guess maybe a course of mebendazole before things “mature” might be a safe strategy.

Dubai

On the way back we spent a day and night in Dubai. Besides a few sneaky merchants and a sketch hotel, it was a great experience. I loved: the savory hummus, extra helpings of falafel, a coast with a warm breeze reminiscent of Corpus, hanging and speaking Spanish with a Colombian back packer, eating Dunkin Donuts, seeing a Hardees, and gazing at a beautifully lit mosque at night.

Back To Africa
Since coming back from vacation things have been moving fast. I’ve been back to Mokhotlong (check out the pics of A Tale of Two Cellulitis Cases: two women in red dresses in two different cities presenting within a week of each other with right hand cellulitis; the child in the picture has typical lesions of scabies), where I continue the tradition of transporting more people with active pulmonary TB in the back of the Land Cruiser. I stayed at the Louis Gregory Center this time - a farm in a gorgeous valley (pic of the house included). I’ve been traveling on the weekends, and the clinic schedule during the week in Maseru is getting busier (we saw about 155 patients today in clinic). I’m hoping things will slow down a bit during Christmas. I’m having a little difficulty feeling the holiday spirit during the summer in a country that doesn’t really deck the halls. I’ve certainly felt more homesick around the holidays, as Thanksgiving and Christmas are celebrated in full regalia by the Pierce clan. Similar to last year, where during residency I had the good luck of being on inpatient medicine call (albeit with some awesome fellow residents) for Christmas Eve and New Year’s Eve, I’ll be the PAC doc assigned to the Children’s Medical Ward at Queen Elizabeth 2 (QE2) hospital. While being around kiddos during the holidays is usually a welcome opportunity, unfortunately it seems half or more of the kids we admit to QE2 die during hospitalization. Infant and child death is so common here. This specific contrast between here and the States will always simply blow me away. The death toll certainly wears on you, whether you’re a visitor or a local (a South African nurse’s child told her, “you don’t smile any more”). But every day that we see a baby or her mom die of malnutrition or TB, we see a hundred more that are healthy, running around, gaining weight, and smiling thanks to the medicines and the people that we work with. I am so grateful to have this opportunity and continue to realize that I get more out of it than I contribute.

Miss you all very much,

Southern African Adventure

2007-10-16T12:44:00.000-07:00

Back From Abroad

Hello. I hope all are doing well. I’ve been traveling a lot over the last 2 -3 weeks, so here is some catch up blogging. The first entry speaks of some of the variety we've been seeing in the clinic, followed by a description of my first trip to my rural assignment, the mountain city of Mokhotlong. Lastly I write about our trip to Swaziland for a conference with a little vacation on either side of it, magnificent Kruger National Park and the suave and vibrant Mozambique!

Tuesday Variety Show

I saw a great variety of patients on one Tuesday at the COE. I’m so happy that I’m starting to get some continuity (patients that I've seen on more than one visit). Started off with a pregnant woman I’ve seen a few times now. She sticks out because she voices her opinion and asks a lot of questions. She’s on HAART due to having a low CD4 count and is about halfway through her pregnancy. We started addressing some of the tougher issues: scheduled cesarean section versus vaginal delivery, for one. That one I can say pretty strongly that a routine vaginal delivery is the preferred route, as her HAART will give her child around a 98% likelihood of delivering an HIV negative infant. Formula feeding versus breast feeding is a much harder issue. Yes, she can probably afford the formula, but that still puts the child at a risk for higher mortality due to other infections, particularly diarrhea and upper respiratory tract infections. No easy decisions there.

Next saw another woman I’d seen before, this time no longer pregnant but a beaming new mom with her one week old baby. She delivered after being on the PMTCT regimen of Lesotho, which is based on the WHO guidelines for resource poor settings. She took AZT from 28 weeks, took her Combivir and sdNVP properly during labor, dosed the newborn with a squirt of NVP followed by AZT syrup BD. So tough to then see that she’s breastfeeding this child, increasing the chance that it becomes infected with HIV, but decreasing the chance that it’s going to die from other causes in the neonatal period.

Later I saw a middle aged woman with possible Ramsay-Hunt syndrome (herpes zoster oticus). She had a few days of fever, L sided ear pain, L sided hearing loss, decreased sensation on the L side of her face, and L sided tongue tingling and taste changes. She had no facial droop or lesions in or around her ear. Seems like either HSV or VZV can cause this. I started her on acyclovir and hope that it helps.

Another mom, this one had weaned the baby off of breast milk, and was now giving only soft porridge for the last 2 weeks. Couldn’t afford formula, couldn’t afford trips to the clinic, couldn’t afford insecticide to kill the fleas that were biting the child (though maybe those were from scabies, since I’ve been itching all night).

Lastly I saw the first presentation of both a mom and child that were both so sick they both got admitted to the hospital together straight from the clinic. The woman had a long hx of cough, fever, and TB exposure (but who doesn’t in Lesotho?) was febrile, was breathing almost 40 a minute, O2 sat around 95%, with L sided decreased breath sounds, dullness to percussion and egophony – most likely pulmonary TB with pleural effusion. The child was admitted for severe malnutrition, dehydration, and sepsis.

First trip to Mokhotlong

Tony Garcia-Prats and I made the 5 hour road trip to Mokhotlong, high up in the mountains of eastern Lesotho. We drove through some pretty amazing scenery. Once outside of Maseru, we were greeted by vast expanses of tan, brown and golden fields highlighted by solitary deciduous trees and small thickets of evergreens along the side of occasional rock outcroppings. The peach trees are still providing their pleasant contrast of spring pink flowers in this rather mute background. The real beauty began once we entered the mountains. Overcast skies with pregnant clouds lay low over the peaks of some very impressive mountains. The road was winding but well paved, and the drive was peaceful and quiet, interspersed with yells from smiling kids running along the road when they saw the pale faces. The steep slopes were dotted with small sheep herds and their herders – young men wrapped in traditional blankets and carrying walking sticks. As we drove higher, the air became cleaner and crisp. When we reached the summit, the sky opened up – releasing pea sized hail in droves. We pulled off to the side of the road to enjoy the storm. As the bolts of lightning became more impressive, we decided that being at the highest point of the mountain was not a great idea and began our descent. We passed the one and only Lesotho ski resort (a single slope with a rope pull that was currently devoid of snow), and besides a lot of rain, we had an uneventful remainder of the trip.

The Mokhotlong District Hospital

Maseru is divided into 10 districts, each with its own district hospital and associated health centers. We found the hospital and grounds to be in very good condition. I was pleasantly surprised to see that the hospital was in a much better state than the run-down central government referral hospital in the capital (the Queen Elizabeth 2 Hospital that I’d mentioned prior). The hospital grounds incorporate adult women’s and men’s wards, a TB ward, maternity ward, maternal child health clinic, the Lerato HIV clinic, a pharmacy, and an outpatient department. Though there have been times that the district has been without skilled doctors, currently the area is fortunate to have 5. There are two Zimbabwean doctors, Dr. Nyamutukwa and Dr. Munzararikwa, two Cuban docs assigned for a 2 year contract, Alberto and Francisco, and Dr. Karumba, a physician from the Democratic Republic of Congo. The African physicians cover the hospital and the Lerato HIV clinic, take a week of call at a time, and do necessary procedures. The Cuban doctors see only the outpatients and do not take call, in part due to their lack of Sesotho language skills and limited English. Some procedures that were being provided the days I were there included chest tube placement for empyema, cyst excision, cesarean sections, orchiectomy for testicular torsion, and closed reduction of fractures. The c-sections are most often done under conscious sedation with ketamine administered by a nurse (scary, if you’ve ever seen someone start to come out of ketamine sedation during a painful procedure). At least one of the providers can do spinal anesthesia, but they avoid it since there are no working laryngoscopes or endotracheal tubes for intubation in case of a complication such as a “high spinal”. The lab is rather well set up. It can run CBCs, LFTs, urea, creatinine, CD 4 (a new and potentially very important machine to check the strength of a patient’s immune system, but no reagents yet and can only do about 15 tests a day). The microbiology capability includes gram stain and culture of infected secretions, urinalysis and microscopic evaluation, smear for acid fast bacilli, CSF gram stain and India ink evaluation. There are no blood or CSF cultures, no electrolyte machine, and no other “fancy tests”. Diagnosis of HIV in children less than 18 months of age needs a special machine that doesn’t exist in the area (nor in the entire country). We send dried spots of blood on a special paper card by DHL mail to South Africa, receiving the results in 4 -6 weeks.

Lerato Clinic

The one clinic on the hospital grounds that sees HIV positive patients is also the smallest clinic on the campus. It has no electricity, no water, 3 rooms (waiting room/vitals, nurses’ room/counseling room, doctors’ exam room/blood draw room). Besides the small waiting room, there is no place to get out of the rain (they built a covered waiting area but it caught fire the day after it was finished). I saw a woman at the end of the day who had missed her period, had new onset lower abdominal pain and a new vaginal discharge – but no pelvic exam (I was seeing her in the nurses’ room which had no bed or table, and it was twilight and we had no electricity), no urine pregnancy test available at that time of the day (to help evaluate for possible ectopic pregnancy). Luckily she lives so far away from the clinic that she had to find shelter in town. At least she should be able to make her way to the hospital if it is an ectopic that gets suddenly worse tonight. The last patient of the day was a woman that “had no problems, just here for medicine refill” according to the nurse. A quick glance by the almost non-existent light of dusk showed that her CD4 count had been steadily decreasing while on anti-retrovirals. This suggests that she “has a problem” and shouldn’t just be getting a medicine refill. Luckily she also wasn’t able to get back to her mountain village and will be seen tomorrow in the daylight.

“Rural” Health Clinic

While Mokhotlong is far removed from the capital of Maseru, it is still a sizeable city. We jumped in the UNICEF Land Cruiser and visited the health center in the small town of Libibing (pronounced: Dibibing). Here, there is a small health clinic staffed by a nurse, a nursing assistant, and a social worker – much more support than most clinics of its size. Besides a room to see patients, they have a basic pharmacy, including recently accrued antiretroviral meds, a few beds, a delivery room, and two waiting areas that can also be used for patient education. Just when I thought this was the end of the line, it seems like patients still have to walk long distances to be seen here – even up to 3 to 4 hours. I asked a woman how long it took her to walk to the clinic and she answered poignantly – it depends if I am health or sick. We went on two days, saw patients with the social worker and the nurse assistant (the nurse was out of town at a training) and encouraged the patients and their families to be tested for HIV. There are another 6 rural towns in the Mokhotlong district with health clinics, and unfortunately we didn’t visit any of them on this trip. The next sojourn up to Mokhotlong will be in mid November, and we plan on addressing many issues, including: PMTCT (what is being done in the rural clinics as well as the district hospital), visit the remainder of the rural clinics, plot out where and how we will be building the new BIPAI funded family HIV clinic on the district hospital campus, attempt more testing to diagnose HIV positive children and their family members in the rural periphery, and continue to train the local doctors, nurses, nurse assistants, social workers, and community health workers/expert patients. I liked the feel of the area, and I think we’ll be spending more time up there – maybe a few weeks at a time.

Happy Hour In Maseru: Jowling Update

Still lots of work to do with the Lesotho Jowling team.

Kruger National Park

We took off Thursday morning, October 4th, to Kruger National Park in north east South Africa. The group was made up of myself and Anu, along with the 3 current Lesotho visiting scholars - Megha Patel and Amit Singh, two visiting med students from Baylor, and Djin-ye Oh, a visiting resident from Germany. Thursday was Independence Day in Lesotho, so the line was long, even at 8 AM, at the border crossing. In line we met a small group of Peace Corps volunteers, getting away for a little much needed R and R themselves. The drive from Maseru, Lesotho, to Hazyview, the little town outside the southern portion of Kruger Park was a little long but filled with some beautiful vistas. The early portion was the same road we took to Clarens a few weeks earlier – magnificent buttes jutting out of a rolling, light green and tan landscape. There was a stretch south east of Joburg that reminded Anu and I of West Texas – pretty brown, pretty flat, and not too exciting to drive through. But just within an hour of that we got into a valley that started out like Sonoma County – complete with “golden” hills, then with eucalyptus and then evergreen trees. The main differences from northern California were the street signs - like “hippopotamus crossing” and “Crockadile River”, etc.
We stopped for a great dinner at “The Fez at Bagdad”, a great fusion restaurant in a fancy little area of White River, the town outside of Hazyview. After 7 hours of driving, we feasted on bruchetta with soft goat cheese, great 12 dollar bottles of wine, a warm pumpkin/feta/lime-infused red onion and pine nut salad and chocolate polenta cake.
We rolled into “Hazyhaven”, a pleasant little bed and breakfast in Hazyview, run by Dawie and Shirley Malan. We definitely feel like we lucked out – all of the places we were calling the night before our trip were either closed, full, or too pricey. Hazyhaven turned out to be clean and cozy, with a pool, and breakfast provided, all for about $35 a night.

Big Animals

We spent both Friday and Saturday driving around Kruger Park. Instead of being in a big safari 4x4 driven by a local with a blunderbuss, Kruger allows you to drive yourself in and do a self-guided tour. It’s hard to describe the feeling of seeing animals outside your car window that you’ve only seen in zoos or on the television. Day 1 brought my first sights of big African animals. These animals really are big. The experience was amazing. Within the first few minutes of entering the park we came across a group of baboons. We pulled to a stop and watched them play in the trees and amble across the street. Just a few minutes down the road came the first views of the deer-like impala (but with horns instead of antlers), followed by the impressive kudus (almost the size of elk, with spiraling horns). Our first sighting of an adult giraffe blew me away. He walked across the road right in front of our car, ate some leaves off of a tree, and then continued on his way. We were lucky enough to also get really close views of an adult male elephant and a pair of white rhino (all of which at one point seemed on the verge of getting too close to our little Volvo). We also captured our first views of zebra, vervet monkeys, hornbills, storks, crocodile, and hippos. The second day, we were joined in the park by our new friend Ursula Jessee, a hip chick living in Joberg who is currently doing research on evicted people there. Under a grey-blue overcast sky and occasional showers, we had a sighting of a beautiful leopard, hippos out of the water, and a family of hyenas (the mom, big and more than a bit scary, approached Ursula’s very little rental car as she smelled the kudu jerky that had been ripening in the car for the last day). After an amazing day of seeing these peaceful animals enjoying existence with their families in their natural habitat, what a better way to wrap up the day than order up some mama kudu for dinner, medium rare. Well, that’s what the carnivores in the group did – I found the shiraz much more appealing.

Jerry Goes to Kruger

As we were on our way to a Baylor International Pediatric AIDS Initiative meeting in Swaziland, we were transporting a mannequin – a roughly 12 year old boy CPR mannequin that we named Jerry, to be exact. After a few hours of fruitless searching for the elusive cheetahs and lions of Kruger, Jerry came out of the trunk for his first views of big African game. He was a little unnerved at first, but much less so than the people in other cars who got a glimpse of our shannanagans (I just realized that I have no idea how to spell shinnanegans). I’d say he had a really good time (see attached photos). The highlight was when we passed him through the window between our cars (it’s illegal to get out of your car at Kruger, for obvious reasons). We think it was also the highlight for the woman in the car behind us.

Baylor International Pediatric AIDS Initiative Network Meeting

Anu, Ursula and I said good-bye to the visiting scholars as they headed back to Maseru, and we headed over to Swaziland. Like Lesotho, Swazi is one of the few remaining kingdoms in Africa, and similarly is in a state of crisis due to the HIV epidemic. With a population of nearly 1 million people, it has the world’s highest percentage of people living with HIV – around 40% in pregnant women and even higher in some age groups (I believe 1 out of 2 people aged 24-29 are HIV positive). As more people get sick with HIV, health care needs increase, but health care capacity is simultaneously falling – there are fewer doctors and nurses alive to take care of all the sick people. The life expectancy just five years ago was 60 years (the US is around 67 yrs). Currently the life expectancy is only 31 yrs of age. Around 70% of the population lives below the poverty line – this is living on less than a dollar a day. There are about 76,000 orphans (about 1 out of every 4 children). This would be like the US having 18 million orphans. Swazi is also known for its laid back pace, natural beauty, and the tradition of polygamy. To make the dire health care situation in Swazi even worse, many of the government officials, including health care leaders, are appointed by the king, seemingly irregardless of their skills and lack of training. Anu and I came to Swazi since we were traveling to attend the Children’s Clinical Centers of Excellence network meeting in the capital and second largest city of Swaziland, Mbabane. We checked into our rooms at the Ezulwini Sun Hotel, a somewhat less ostentatious hotel in the swanky international Sun Hotel chain. The conference was attended by doctors from the 9 countries within the BIPAI system (Swaziland, Lesotho, Botswana, Malawi, Burkina Faso, Uganda, Tanzania, Libya and Romania). Much was shared between groups and hopefully the care of HIV positive children and their families will be improved because of the effort.

Mozambique: Nao e tudo bem!

Ahh, Mozambique. What can I say? Moz was more than I had expected. It is one of I think only two Portuguese speaking countries in Africa, the other being Angola. Immediately upon crossing from Swaziland into Moz, you could feel a difference. The energy of the country – its people, culture, and food to name a few points, was a level above. Moz, as some of the gringos call it, is definitely the most Latin American feeling place I’ve been to in Africa. The Holiday Inn, where the people with foresight stayed, was a beautiful beach front hotel unlike any Holiday Inn I’ve ever stayed, complete with a pool overlooking the Indian Ocean. I definitely recommend it as a great place to chill with a local brew, perhaps a Laurentina Clara or a 2M beer. A fellow PAC doctor working in Lilongwe, Malawi, Chris Buck joined Anu, Ursula, Anouk and me at the Hoyo Hoyo hotel, which was Spartan, to say the least – closer to solitary confinement to be more descriptive. We had a lot of fun speaking Portuguese mixed with Spanish and English, enough to maneuver around the city and get moderately ripped off by the merchants. The dining experience was great for the carnivores but left a lot to be desired for those of us who don’t like hurting the little fishies. Regardless, the fish market was an impressive place, with row after row of fish, large and small, shrimp, octopus, lobster, crab, prawns and mussels. You could walk through the market, pick your kill, and they’d take it back to the kitchen, douse it with butter, lemon, salt and other spices, and bring it back to you on a platter, fresher than anything you’ve seen at Red Lobster. A number of the group almost registered as permanent Mozambican citizens just so they could eat there a few times a week. We went to a night club looking for glimpses of the famous dancing skills of the mozambicanos, but were disappointed as three separate djs on separate dance floors played their own mixes of bad and worse electronica and hip hop. For their credit, the locals could dance well, just not to the music I was hoping to see them dance to.

On Saturday, while bargaining with over-zealous artists in the local craft market, I got a text saying that part of our group was relieved of their cameras by some of the local miscreants (who were possibly rugby enthusiasts). Luckily our folk were relatively unscathed, though it seems that when you finally find the police station to report the incident, the officials aren’t particularly likely to rise to the occasion (a huge surprise to the readers out there who have traveled in developing countries, I’m sure).

My respect for the law was not strengthened when we were stopped later that night for making a “mildly” illegal U-turn. The three cops were on foot and only had one AK 47, for the record, so we could have likely gotten away, but instead we decided to talk a little while with the nice gentlemen. To his credit, Buck did a decent job with the bargaining game. He was able to negotiate the cop down from a 150,000 US dollar fine, a trip to the station, plus having his passport revoked – all the way down to a whopping 12 US dollar fine. I wish I had negotiated that well at the crafts market.

On the way back, we enjoyed a glimpse of a zebra at the outskirt of a park, wishing us good bye from northeastern South Africa. It was a good 10 days away from Lesotho. To travel is nice, but it will also be good to start seeing patients again. There is so much to be done, and I often feel the pull to get back to it while away from the clinic. I also feel very fortunate to have the ability to travel. Such a small percentage of the people living on this continent can do so. So much beauty abounds here, from sunsets on a Mozambican beach, to baby giraffes grazing with their mothers, to mountain scapes stretching across the land of the Basotho. In 10 days I’ve been able to see all of these things, with relatively little hassle, and for little money out of my pocket. The disparity is brought home more emphatically as we drove past the shanty towns outside of Joberg. It’s not fair. Not at all.

Sick patients, the Mohale's Hoek and Jowling

2007-09-24T08:22:00.001-07:00

September 17 - September 23

Clinic

I started the week off in the COE (center of excellence), the main Baylor clinic, and then worked a few days in the Bophelong clinic. Bophelong, attached to the Queen 2 hospital, is the first pediatric HIV clinic in the country and was in part sponsored by the Clinton Foundation. Mondays at the COE are our busiest days, more so than in the States as patients and their families use the hospital ERs less (more roaches and fewer doctors than our ERs). As is starting to be the routine, I grabbed patient files from the “family” box; these are usually adult women, sometimes pregnant, sometimes also here with one or more of their HIV positive kids. We are seeing some adult men, but most of them go to other community clinics. Patients coming for their first visit to the clinic are often quite sick. Due to a mixture of factors, including lack of knowledge of their diagnosis, denial, and poverty, they often have very weakened immune systems and the various infections that go along with those lapsed defenses. On Monday I saw an adult woman who was new to our clinic. I could tell right away that she was very ill. Pale and trembling, she slowly met my gaze with a mostly vacant stare as she was led by her much more attentive mother (so often the grandparents are the healthiest ones in the family, as they have escaped – for the most part – being infected with HIV). Ironically, the woman’s small child was already a patient at the clinic, on meds and doing well; she had made sure her daughter was in care but had not been able to get herself tested and enrolled in care. With a constellation of symptoms including confusion, fever, weakness, cough, vomiting and diarrhea I knew that there would be no straightforward diagnosis, especially with our relative lack of available tests. We scratched our heads, thinking that her advanced state could have been due to a myriad of opportunistic infections, including tuberculosis, mycobacterium avium complex, pneumocystis jiroveci infection, cytomegalovirus, systemic fungal infection, toxoplasmosis, cryptococcosis, or just HIV itself. We drew blood and CSF (no manometer to gauge the opening pressure, but in retrospect it looks like you can just use IV tubing attached to the end of the spinal needle and then measure how many centimeters of elevation the pressure of the leaking spinal fluid causes) for what tests we have available, started empiric antibiotic therapy, gave her a request for a chest X ray from the public hospital, and sent her out, hoping that she’d be able to return the next day for follow up. I definitely would have admitted her to the hospital if we had been in the US. She came in each day to the clinic as we drew blood for a few more tests and added more and more antibiotics – treatment for as many of the infections that she could possibly have based on her signs and symptoms.

Last week in the clinic I saw some stuff that floored me. There was a post partum hematocrit (NOT hemoglobin) of 8 which was drawn AFTER the one unit of blood available for her at the hospital. We had to drive out and find her in her one room home as she was an OUTPATIENT. She was not quite, but almost, as pale as I am - though her S4 and tachycardia were much more impressive than mine. The next day we took her to the hospital for a blood transfusion but she left because her baby was hungry and the line at the ER was too long. I saw a child with a multi-dermatomal herpes zoster scar that was so bad I thought for sure she had been burned in a fire. I saw an adult with a new diagnosis of AIDS and an absolute CD4 lymphocyte count of 3, as well as a child with HAART treatment failure whose CD4 percent had dwindled down to 1% (severe immunosuppression is defined as 15% or less). Saw another 9 year old in the outpatient clinic who was as tall as a 4 year old (probably due to a combination of HIV, malnutrition, and repeated infections) and had a CD4% of zero.

As an add-on patient at the end of the day I saw a young girl who had fever, cough, and night sweats, had recently been treated twice for pneumonia but never improved, had multiple family members that had lived in the same house as her and been treated or died from TB, and whose parents both had fever, night sweats, cough, and weight loss. In the US, with the very first case of active TB, a public health organized contact investigation would have been initiated, and the children in the house would have had a work up and possibly been started on treatment or prophylactic medications depending on symptoms. Here, there is no such thing, and unfortunately we’re getting kids that show up during or after treatment for their parents has been completed. We started her on presumptive TB treatment, gave the parents a slip for chest x rays and sputum samples to see if they are truly infected, and just hope that they actually do what we recommend. They might not go for diagnosis or treatment if they don’t think it’s really that important, if they can’t afford the time off from work, or if they think that a faith healer is all that is really necessary. In the meantime, if the symptoms they have are do to TB, they’re infectious and will be coughing on family and friends, spreading this biblical disease as it has been done for centuries. It’s so amazing that little has changed in our ability to combat this scourge. And we’re starting to lose ground, as HIV multiplies infectability and then transmissibility, not to mention the problems that we’re seeing with multi-drug resistant strains of TB becoming more and more common.

Social Life

Friday night we played some mean games of squash, ate at the Indian restaurant, and then watched “So I Married An Axe Murderer”. Saturday was spent at a funeral for one of our clinic’s translators that unexpectedly passed away a few weeks ago. We took what can truly be called an expedition, out to the village where the burial was. Down roads that should never have been traveled in a sedan, a one combi (mini bus) and 4 car caravan inched along for several hours to reach the burial site. Though Christian based, very sad, and held under a tarp, the ceremony was mostly different from the ones I’d been to in the US. Many of the speakers were very animated, with some shouting praises at the tops of their lungs while pacing in front of the crowd. The singing was better, mixed with rooster calls and dogs barking; and there were more cows and geese walking around. The wind was at times overwhelming, and it brought a red dust that covered the funeral goers’ clothes and caused them to cover their faces with colorful scarves and tissue. I had an image that the gusts were whisking her spirit away from these clumsy earthly shackles, bringing it back to the greater Spirit from where it came. It was a full 12 hour trek, and though really tired at the end of it all, we felt closer to the staff – and to life.

Saturday night was the 2007 Maseru “Beer Fest”. I use quotations here, as what my expectations held it to be and what in reality it turned out to be were two very, very different things. To preface why I was so deeply crestfallen, my last beer fest (no quotations) was held in Santa Rosa, California. It brought representatives from some of the best microbreweries of Northern California and Oregon. In addition to one of God’s finest creations – Damnation, a golden Belgian-style ale brewed and served in Santa Rosa’s Russian River Brewery (the living room), the selection included Brother Thelonius from Fort Bragg, Boont Amber from Boonville, and a delicious blueberry ale from the Bay Area, to name just a few (I’m beginning to salivate). The entrance fee bought you all the draft beer you could drink, in addition to gourmet cheeses, organic foods and Trader Joe’s peanut butter filled pretzel pockets (yum). The Maseru “Beer Fest” entrance fee bought you, in comparison, all-you-could-eat sausage, rather old appearing deli meats, pretzels made in the 1980s and all the bad Southern African bottled beer you could buy. The night did have its high points, as I introduced jowling (http://www.jowlers.com/ - search for pierce) to a British soccer player and some of the Clinton Foundation workers. See attached pictures.

Until next week,

Blood Sick Doctor

2007-09-16T13:02:00.000-07:00

September 10 – September 16

Hello, and welcome to my blog. A big thanks to Cindy Su and Bruce Heller for convincing me to stop sending out group emails and finally setting up a blog. I’ve up-loaded the old emails as well and added a few pictures. Enjoy!

Clinic

On Wednesday I was “blood sick doctor”, the rather ominous sounding title for the doc who is in charge of reviewing the labs (“blood”) and being available to manage the “sick” kids that come in the door. Now, some would say that all of the patients at an HIV clinic in southern Africa are sick, but really most are fairly healthy. Granted, they might have pulmonary tuberculosis, pelvic inflammatory disease or strep throat, but they’re walking in by themselves and can usually walk out just as fine after a routine clinic visit. The sick visits are the kids that are decompensating and need stabilization before sending them out for them to return to the clinic the next day or for admission to Queen Elizabeth 2 hospital (QE2). These are the ones who need oxygen due to asthma attacks or bad LIP (lymphocytic interstitial pneumonitis), the kids that are acutely dehydrated and need ORS (oral rehydration solution), or as was the case on Wednesday, the ones with pneumonia, severe malnutrition, bulging fontanelles and 4 days worth of seizing. First was an adolescent with cough, fever, fatigue – hopefully just a community acquired pneumonia, I chose high dose amoxicillin and clarithromycin and told them to follow up before the weekend if she wasn’t doing better. Next came the infant with severe malnutrition, regional BCG disease (swollen vaccine site on the arm and a large ipsilateral axillary node), and a bulging fontanelle. We performed a lumbar puncture, gave antibiotics for possible meningitis, started TB treatment, ordered a chest x-ray, worked on the refeeding schedule and (you might be guessing “admitted the child”) sent the child home to follow up in 2 days. Last was the real sick child. Another infant, this one had been seizing for 4 days and was finally referred to us from a community clinic. A rectal dose of diazepam, though paraldehyde (yes! From MUDPILES) was also considered, calmed the seizures initially. We performed another LP and this time the fluid looked like someone had spit a loogie (lugie?) into the test tube. I have never seen frank pus slowly ooze out during a tap until today. We did a quick gram stain on a drop of the CSF, looked at it under the microscope and saw tons of white blood cells and gram positive diplococci in pairs – most likely Streptococcus pneumonia causing the meningitis. Unfortunately there is no pneumococcal (nor H.flu) vaccination program in Lesotho. As the child had begun seizing again, we dropped a nasogastric tube, loaded him with Phenobarbital, and admitted him to QE2 for intravenous antibiotic treatment with high dose ampicillin (100 mg/kg Q 6 hours) and once a day gentamycin (7.5 mg/kg/day). His prognosis is not good.

Social Life

Baylor vs SOS orphanage

This Friday our clinic took on our neighboring orphanage (not the orphans, but their adult staff) in a fierce (not really) football (soccer) match. Basically, the Baylor team is made up of the local staff (cleaners, guards, translators, drivers) that rock and the white doctors (sorry Anu) that suck, with the exception of Tony, one of the returning PAC docs. I have never played soccer, except when I would get my butt kicked once a year by the small barefoot boys in the Honduran village where Baylor has been building a clinic. I have no skills with my feet. None. Granted, I am able to run quickly from one end of the field to the other, but it’s mostly pointless since none of the locals purposely pass me the ball. Nonetheless, we tied, and we had more fun, too. The women from the clinic sang songs throughout the match and would flood onto the field when we scored. Now all I have to do is get them into Ultimate Frisbee…

T-Y

Saturday we took a day trip to Teyateyaneng, or T-Y for those of us that can’t pronounce it. It’s famous for its hand woven tapestries and rugs. I took some pics of some of the good ones. Aside from a brief near death experience when we were accidentally driving on the wrong side of the road, we had a great time.

Basotho Hat

Sunday morning started with an amazing brunch at Seema and Guada’s house – pancakes (with the much coveted real maple syrup – hand delivered from North America), quiche, fruit salad (guava, papaya, kiwi, strawberry), and banana bread, among other things. The table was full – PAC docs, Nick (a visiting med/peds resident from Houston), and Djin-ye (a med school graduate from Berlin). A quick trip after brunch to QE2 showed that the infant with meningitis was still alive, then off to hike up the mountain where the past kings and royal family are buried. The hike was great – a cool breeze accompanied us up a hill with some good rock climbing (left my climbing shoes and chalk bag in my closet), free roaming horses, scrambling lizards and expansive views of mesas and plains dotted with evergreens and cacti. We saw the famous conical hill where one of the early past rulers hid from his enemies. The shape of the hill then became the design for the unique basotho hats that many of the locals wear and is one of the main cultural icons for the kingdom. Hope all are well. Let me know what you think of the blog; until next time –

Queen 2 to Bloem

2007-09-14T05:21:00.000-07:00

September 3 – September 9

Clinic
The pace is picking up a little in clinic as I get used to the clinic routine. I’m getting accustomed to the electronic medical record, the referral forms, the questions I need to ask, and even picking out some of the Sesotho phrases I hear the patients use like, “why is that white doctor so hairy?” (though still don’t know when the official language lesions are going to start). I’m getting a little more comfortable with managing the 3 year old HIV positive child on active anti-tuberculosis treatment who presents with moderate wasting (acute malnutrition). Just a little more comfortable. Almost every day I see a patient that has a dermatologic finding that could be placed in a dermatology atlas. We actually have this great teledermatology resource. We take a photo, include the patient’s history, send it to a dermatologist/dermatopathologist in Philadelphia with specialty training in tropical medicine who then emails us back her opinion. Very nice. She even accepts biopsies that we DHL to the States. So far I have taken pics of (what I think are): a pyogenic granuloma on a pregnant woman’s cheek; oral hairy leukoplakia of the lateral tongue, widespread flat warts around the face and neck of an adolescent, nail discoloration possibly due to AZT, chronic, widespread molluscum contagiosum, and some sort of benign mucosal hypermelanosis. I’ve also seen what’s most likely inguinal adenopathy from lymphogranuloma venereum, scrofula, a fair amount of herpes and possibly some secondary syphilis and PID.

Queen Elizabeth 2 Hospital
I went to QE2 on Friday and was reminded that I was in Africa. This public hospital truly has a major lack of funding. It makes my “old” community hospital from residency look like the Westin. Plaster was falling off the walls and ceiling, you have to dodge holes in the floor, you try to ignore the occasional many-legged critter on the wall, and LPs are done without iodine, sterile gloves or spinal needles when supplies are out, to name a few of the specifics. The “pediatric ICU” is a small room with one oxygen concentrator (not an oxygen tank, but a machine that can concentrate the room’s oxygen and deliver it up to about 5 L/min) that has 3 to 6 tubes snaking off it in a jumble of tubing in the middle of the floor, each going to a different patient sharing what little oxygen the machine can produce (sometimes you can't even feel the flow of oxygen on your hand; unsure if any reaches the alveoli). There might be a 6 week old sharing a crib with a 4 month old, next to a bed with a 9 year old, all with different ailments, many of which are likely passed fairly freely between them (“here, try my infection; ok, now I’ll try yours”). There is one dedicated pediatrician on the ward (Dr. Phiri, a Malawian woman who has been working there for decades) and about 3 medical officers – people that have graduated from medical school but seem to be stuck, thanks to a lack of funds that would allow them to go out of country to a regular residency, in an odd permanent internship with no lectures, no hope for advancement, and no Thursday group sharing sessions. But damn, can they find a vein. All of their training is on the wards, and they have to start all their IVs, draw all their blood, do the LPs, drop the nasogastric tubes, deliver the specimens, etc. The nurses’ sole responsibility is to give medications (we prescibe Qday dosing whenever possible). There is no phlebotomy, nurses don’t give food (parents feed their kids, but unlike poorer hospitals, they at least don’t have to cook the food as there is a kitchen), people don’t come to pick your patient up and take them to radiology, and there are no Wellness Dogs (though I did find a woman with a monkey in her hair, but that was at a restaurant in South Africa). We see the HIV positive kids that are admitted from our clinic. These are very sick kids, as even the pretty sick kids we try to manage as outpatients since the mortality is so high in the hospital (no attendings or residents in the hospital after hours, and sporadically on weekends). We’ve recently had sort of a neuro service: a 7 month old with severe wasting, dehydration, and likely meningitis with a blown pupil but flat fontanelle, a ~9 month old with possible idiopathic intracranial hypertension (pseudotumor cerebri from…?hypervitaminosis A, iron deficiency anemia, HIV itself?), an adolescent with likely viral encephalitis that growls, kicks, and occasionally goes AWAL, and a toddler with brain lesions of uncertain etiology, subsequent hydrocephalus and Cheyne-Stokes breathing, seizures, and possibly temperature disregulation due to the CNS damage. They are all managed by, that’s right, us. That’s not to say that we manage them exceptionally well; we do what we can. No quick calls to Dr. Warner to manage the case for us, no going down to chat with the neuroradiologist about the differential. Thankfully, the internet really helps, and I’ve written some emails and sent some pictures of CXRs and CTs to friends in the US.

Social
Took a good trip to Bloemfontain, a city of 500,000 in South Africa about 1.5 hrs away from Lesotho. We found hearty food and drink, soft-serve ice cream, and The Simpsons Movie (only 2 bucks!) all at a cheesy waterfront mall. Really made me feel like I was back home. Went for a great run up a big hill near the house. After the chest and jaw pressure subsided I noticed that there was a great, nearly panoramic view of Maseru up at the top. Bright, clear blue skies and 70 degree weather – so this is Africa.

Week In Review

2007-09-14T05:14:00.000-07:00

August 27 – September 2

CLINIC

Seeing patients and PMTCT:
We (the new PAC docs) have started seeing patients fully on our own now, with help from our friendly translators (some of which are openly HIV positive and are community activists). The oversight and teaching is great – I can stick my head out an exam room door, pull aside one of the “veteran” PAC docs and ask questions like, “Do you think this is TB or pneumonia”. We also have lectures during the week. It’s amazingly like residency, or perhaps more accurately like a fellowship in HIV in Africa. I’m seeing somewhere around 50% peds and 50% adult women in the main clinic in Maseru. Many are relatively healthy, doing well on their HIV meds with few complications. Many are stunted (short stature due to chronic malnutrition), and some are wasted (acute weight loss associated with sudden illness). There are a few adult male patients in the clinic, but most of them go to the adult HIV clinics in town, including the HIV center down the road. That clinic is called Senkatana, named after the legendary hero that slayed the giant monster that was eating up all the people of Lesotho. It’s a nice metaphor for the country’s attempts to conquer HIV. Mike Tolle, Texas trained family physician and all around great guy, has just finished his year as a Lesotho PAC doctor and has started working in the department of retrovirology in Houston. Along with the internist in the group, Matt Gralewski, they had been doing the brunt of the antenatal clinic work for the clinic. It’s a little daunting being the only formally trained family doctor in the group. Matt is great and has been teaching me a lot about the prevention of maternal to child transmission of HIV (PMTCT). We concentrate more on HIV care than basic antenatal care, though we do perform some basics. We have this great “portable” Doppler machine to hear the fetal heart beat. It weighs about 20 pounds and is made of what looks like metal from a WWII tank, but it works alright. I’ve also been using a metal cone to find the heart beat when the machine isn’t around. When the room is very quiet and the pregnancy is fairly far along, you can actually hear the heartbeat decently well. If anyone has a somewhat more portable Doppler that could use a new home, let me know. Like many parts of the developing world, Lesotho has a long way to go with PMTCT. In the States, just about every HIV positive woman is placed on at least 3 HIV drugs, known as highly active anti-retroviral therapy (HAART), every day for most of her pregnancy in order to prevent the baby from becoming HIV positive. In a non-breastfeeding woman/baby pair, this means that women on HAART pass the infection less than 2% of the time, as compared to 25% of the time without any medications. In very poor areas of the world, where women don’t have access to HAART due to a combination of lack of expertise, funds, and infrastructure, the most basic PMTCT prevention involves a single oral dose of nevirapine (NVP or Viramune) to the mother and a single dose to the newborn infant. This reduces the transmission to about 12%, again in a non-breast feeding couplet. As simple as giving one drug to mom and baby that would cut the rate of HIV transmission in half, only about 5% of women in Lesotho get this. There are about 50,000 deliveries a year in Lesotho, where more than 1 in 4 of the women are HIV positive; and the rate of transmission from mom to baby is about 40% without treatment. Without PMTCT about 5,400 children are born HIV positive. Without pediatric care of HIV positive kids, about 30% of these children die by 1 year of age and 50% are dead by age 2. We have some work to do. We are scaling up the PMTCT, with the following goals:
Most pregnant women get the WHO recommended regimen for pregnant women in resource poor settings, which involves a few drugs and cuts transmission to about 6% (18% if breastfeeding).
Those women that have more advanced disease get HAART, just like the women in US and other resource rich settings, cutting the transmission to about 2% (around 8% if breastfeeding).
At the very least, when the above two goals cannot be met, all women get at minimum the single dose NVP.
Breastfeeding is another huge topic that I won’t get into now except to say the following. Breastfeeding is not recommended for HIV positive moms in the US since HIV is passed in breast milk. Breastfeeding is recommended in many parts of the developing world for HIV positive moms because formula often is not accessible, feasible, affordable, safe and sustainable. A significant proportion of children in such settings die of diarrhea and malnutrition when they are on formula instead of breast milk.

SOCIAL LIFE

Live music in Lesotho and 5 Legged Cows
During the week we went to the local fancy hotel the Lesotho Sun to hear No Jazz, a group of young musicians from France on their African tour. The event was hosted by the Aliance Francais (something like that). Though there were no French fries or French bread to be found, we did enjoy some progressive French “jazz” – an interesting mixture of rap, spoken word, and synthesizer in addition to the more traditional sax, trumpet, keyboard and drum set. For the whopping entry fee of 90 Maloti ($12 US dollars) we enjoyed one free drink on the house and the chance to rub elbows with the Lesotho elite. Friday night was a going away party for some of the Partners In Health workers (working with HIV and drug resistant TB) where I met a Frenchman who had never heard of Zinfandel (“Wat ees dees Zeen that you speak of?”). Shocking; I suppose Zin is more of an American thing. Saturday night brought a house party at one of the Clinton Foundation worker’s houses, complete with wine and cheese, vodka soaked fruit and Jello shots (yes, Jello shots). Afterwards we went to Good Times Café where we danced to the vibrant jams of a local band headed by a great Masuto female vocalist. Sunday morning we went to our first Hash. This international organization is a slightly strange, fraternity-like gathering of ex-pats who hike once a week, chant rhymes and enjoy a beer after the hike. Just a little drive towards the outskirts of Maseru, the hike brought us some of our first views of the “real Lesotho”: winter tan and brown plateaus and montains with smatterings of the spring pink peach tree blossoms, roving sheep and cattle herders and a five-legged cow. Yes. That’s right. At the end of the hike we came upon a calf with a fifth, fairly small and most likely unhelpful, leg growing off of its neck. Cow manure, you say. But really; we have pictures.

Cheers,

Jeff

The Second Week

2007-09-14T05:04:00.001-07:00

Sunday, August 26, 2007

It’s Sunday night, and we’re finishing up our 2nd week here in Maseru. I’m settling in more, and I feel more at home in this new land. I catch myself, as I look out my back yard into Lesotho and a little further away into South Africa, and say – wow, I’m living in Africa. It’s somewhat strange that I have to remind myself. I often feel that this is just another trip during residency – another elective where I’ll learn a little more about developing world medicine, see some cool sites, meet some hard working people, develop a brief bout of dysentery, and then jump on a plane after a month or so and get back to work in the States. But this time is different. I've signed up for the long haul, and it’s just really starting to sink in. In many ways, this experience is very much like residency. We are a small cohort of co-workers, many of which are new and not knowing exactly what to expect. We’re seeing things that we’ve read about but mostly have never seen before. We have new responsibilities, and we’re inundated with new terms, paperwork, rules, and expectations.

Clinic
Last week we (the seven new PAC docs) sat for lectures given by the veteran PAC docs and local staff (nutritionist, social worker, clinic director, etc.) and also saw patients. One of the returning docs is Tony Garcia-Prats. He is the oldest of 10 brothers, son of a neonatalogist and a graduate of Baylor College of Medicine, where he went to medical school, did his pediatric training, and then did an extra year as chief resident. He is a very good teacher and a great guy. He and his wife (Rachel, a biostatistician) have signed on for an additional 2 years in Lesotho. The patient visits are amazing - amazingly interesting, challenging, and while often very sad, also inspiring (Disclaimer: while writing about patients’ stories I will alter and omit details in order to protect their privacy. I tell their stories not for shock value, but to communicate their struggles so that those who learn of them may be better aware of their plight and be better equipped to aid them). One visit involved a woman in her 30s who had given birth to 6 children. Three of her children had died of unclear reasons (sadly this is not uncommon; child mortality is very high in many sub-Saharan countries). She was in clinic with her youngest, an 8 month old child on triple drug HIV therapy (life saving but toxic therapy, needing daily or twice daily, constant and exact, dosing), also taking multivitamins, iron supplementation, and some cough syrup for a “cold” that had lasted for 2 weeks. Like most children in most countries outside of the US, he had received a BCG (Bacille – Calmette Guarin) vaccine at birth to prevent severe types of tuberculosis infection (meningitis and disseminated, or miliary, TB). BCG is a live but weakened mycobacterium similar to TB that makes the immune system think that it’s been infected with TB, so that the body will be more prepared to fight TB in case of infection. As is seen in some immunocompromised children after receiving the vaccine, he developed a BCG infection at the vaccine site on his arm. The infection and inflammatory reaction spread to a lymph node in his axilla, which swelled and burst, leaking pus (unpleasant). Fortunately it was already starting to heal by the day of his clinic visit, and we prescribed no new medicines (pleasant), though sometimes treatment with anti-TB drugs is necessary. His “cold” was most likely an infection of his lungs (pneumonia), so we started him on antibiotics (high dose amoxicillin in this case, though we have no idea of the resistance patterns to amox in Lesotho; but of note the first reports of beta-lactam resistant pneumococcus in the '70s came out of South Africa; perhaps low dose would have been sufficient). He was also quite anemic (less than the normal amount of red blood cells in his circulation). He had been “dewormed” with anti-parasite medications in the last 6 months (a nice image; infections with parasitic worms, especially hookworm, but others as well, are a significant cause of anemia in the developing world), so that base was already covered. He was also on a multivitamin and iron, as mentioned above, to help correct some of the anemia. One of his 3 HIV meds was zidovudine (AZT), a good HIV drug but unfortunately a medicine that causes anemia in many of the patients taking it, sometimes to the point where emergency blood transfusion is necessary. There is no antidote to the anemia caused by AZT; when the hemoglobin gets below 8, patients are switched off of AZT and onto another nucleoside inhibitor, usually d4T (stavudine). The patient’s mother was not sexually active, as her husband, who had never been tested for HIV was afraid that he might get HIV from her (sad and ironic, since he is most likely the source of her infection). Even though not sexually active, she requested injectable birth control, since she did not want to have another baby in the event that she was sexually assaulted. As highlighted by this example, HIV and TB, while often called infections of the poor, are more accurately described as infections of the powerless (and marginalized). Fortunately, there is a center for abused women and children in Maseru, and I intend to learn more about it.
The pathology at the clinic is truly amazing. While in residency, my typical day in the clinic (assuming no Cambodian patients) would look something like: 68 y.o. man with hypertension, diabetes, obesity, and hypercholesterolemia; pregnant woman with heartburn; 8 y.o. well-child visit for vaccines, newborn baby check up, 28 y.o. woman for well-woman exam, etc. The few visits I’ve attended here were, in addition to the above mentioned case, a 2 yr old who weighed what a 9 month old would weigh in the States, a toddler with active pulmonary TB, a 5 year old that only says 2 words due to the effect HIV has had on his brain (HIV encephalopathy) – he is about the size of a 2 year old, and his mom almost died in the hospital earlier this year, and an infant with oral thrush that looked like a skeleton due to acute and chronic malnutrition and dehydration (skin tenting, sunken eyes, etc). Patients, like this infant, that would be managed in the hospital and intensive care unit are often managed as outpatients due to necessity. Part of this is because at the local hospital: there is no pediatric or neonatal ICU, at night there is 1 nurse for about 30 patients, there are no residents (though some sort of medical officers due cover the wards), the attending physicians are few and far between, there are deaths most every night, and so forth. I can barely imagine what it’s like in the more tropical countries with similar health budgets but that are also ravaged by additional scourges such as malaria, schistosomiasis, and dengue. To its credit, the hospital has imaging available: x-ray, a CT scan (albeit old, works intermittently, and it gives off more radiation than modern ones do), and an ultrasound. It also has lab facilities (CBC, electrolytes, BUN/Cr, HBsAg, CD4, HIV EIA (no viral load) , transaminases, and limited microbiology) that might even come back the same day if you get the blood there before noon, M-Th.
In addition to the work in the clinic in Maseru and rotating through the hospital, we’ll be going to rural sites throughout the country. I’ve been assigned to Mokhotlong, what I hear is a beautiful town in the mountains near the famous Draakensburg (Dragons Mountains). Around 5 hrs by car or 45 minutes by small prop plane, it’s one of the sites where we’re upscaling pediatric HIV care and prevention of mother to child transmission of HIV. I’ll spend a few days to a week in Mokhotlong every few weeks – consulting, teaching, and generally just helping out. This is supposedly the “real” Lesotho – up in the mountains and the snow, surrounded by amazing vistas, treating the sheep herders and their families, and preventing more babies from being born HIV positive in the Kingdom in the Sky. Romantic, huh? In reality I’ll probably be freezing my nalgas off under a mohair blanket, wishing for fast internet and mocha chai fat free latte cappuccino. We’ll see – first trip is in October.

Donations
A few of you have asked how you can help. No need to give anything. But if you really want to, all forms of support are welcome, from meditations, prayers, letters, toys, visits, and monetary donations. Our main clinic in Maseru is surprisingly well funded. Nonetheless, there is a list of necessary items: certain meds and equipment are lacking at our main clinic and the many clinics and hospitals that we work at throughout the country. Also, there is a transportation fund for those patients that cannot afford the one to four dollar fee to get to and from clinic. Send me an email and I can check in with our clinic director about how best to handle your donation. I would like to thank Dr. Allison Froese, skillful and compassionate Canadian anesthesiologist and teacher who donated a wonderful laryngoscope and blades to the clinic (while there is currently no working respirator in the clinic or hospital, a child was intubated in the clinic for respiratory failure most likely due to home overdose of seizure medications and was bag ventilated in the back of an SUV during the hour long overland international transfer to Bloemfontaine, South Africa).

Social events
Went to a birthday party for one of the clinic sub-directors the other night. The food was excellent – northern Indian cuisine with great veggie options and relatively few parasites. The company was even better. The 30 or so guests were made up of Baylor AIDS corps docs, Partners In Health workers (Paul Farmer was not present, though it was great to meet these guys that are working both in very rural sites with HIV and multi-drug resistant TB and in the capital building our first TB lab able to run cultures and sensitivies, improving treatment of MDRTB/XDRTB; Lesotho is one of the top 3 countries in the world for prevalence of HIV/TB co-infection), and Clinton Foundation staff (they are mostly public health and business trained people that procure affordable HIV drugs in resource poor settings). How inspiring and humbling to be surrounded by people doing so much for people with so little.

Closing
OK, so the length of these entries is a little insane. See what happens when there are no microbreweries in town? Way too much free time. Thanks for making it to the end. Miss and love you guys lots.

Adjusting

2007-09-14T04:54:00.000-07:00

8/21/07

A week has now passed since arriving in Africa. Since that last communication, life in Lesotho, the Kingdom In The Sky, continues to be good and bring interesting little adventures. Here is a re-cap of what’s been going on.

The Living Situation
Anu (friend from med school, recent Oakland pediatrics grad) and I have moved out of the “Baylor cottage” located on the clinic grounds. We miss getting the free wi-fi internet access from the clinic but enjoy being closer to the center of town and having our own place. We finally were able to unpack that first night after leaving the cottage, mostly to keep warm by constantly moving; the 3 space heaters we had enjoyed in the cottage (including Big Bertha, which is more like a super nova than a space heater) didn’t come with us, and our new house had none. The beauty of 30 degree evenings quickly wanes with no central heating and no space heaters. We did manage to collect some brush and build a fire in the fireplace (I know, why am I complaining?), and that did warm up the place. Our 3rd roomie, Kara Dubray (recent Oakland pedi grad), didn’t make it in that night as expected, and with no phone, we weren’t so sure as to why. Early next morning I had a vague sense of someone repeatedly leaning on their car horn. After I cleaned out the icicles and tundra moss that had grown in my ears during the evening chill, I realized that Kara had simply missed her connection and arrived the next morning instead. The house has a “guard”, Isaac, who is a tall Basuto young man of 29 yrs. It’s mandatory that we keep him, per BIPAI, and I suppose it’s a good thing to help give another local a living. His official watch is from 6 pm to 6 am. He speaks a little English, we speak a little Sesotho; basically we have no idea what the other person is saying. The best we can figure out, his routine involves talking over the fence to the next door neighbor’s guard in the early evening, then around 730 pm he retires to a side room, wraps up in his customary Basotho blanket, turns on the heater, and falls asleep. Usually, when a guest honks their horn outside, we are able to beat him to the gate (“Yay, I won again”). He does enjoy the food we bring him (Anu is impressed how he is able to wake up with just a tap on his door when you have a plate of food in your hand). The house is pimpin’, if you will, with a great stoop (porch) for stoopin’, which involves sitting on the stoop and drinking beer and or wine. There is a eucalyptus tree, sans koala, a fenced off “garden” that currently resembles two elephant-sized graves, a walk in vault (some previous owners “sold jewelry” we’re told) but currently is just a closet (safest shirts and underwear in all of Lesotho), and all the amenities that you’d expect in a house in the US. No hot tub, but I’ll work on that. Our kitchen is stocked with good foods (peanuts, cereal, cheese, beans, and beer – mostly unchanged from my kitchen in Santa Rosa). Anu likes to cook, so we have chutney, pasta…even veggie burgers. We found out the hard way, tonight no less, that the box on the wall with digital numbers (that count down, though we hadn’t noticed this small but important detail before tonight) tells us how much electricity we have left. Much like a calling card, you add minutes to it at the electricity shop. We came home tonight from soccer to find that we were out of minutes (we were really out this morning; we just thought it was a power outage). Bummer. Thankfully the food in the fridge doesn’t spoil in arctic weather, so the goods were, well, still good. As the Basuto government realizes that most foreigners are ignorant to buying electricity minutes, the store is open 24 hrs for just such occurrences. So with help from the clinic sub-director (after she stopped laughing), we figured out what went wrong and were back in business.

The Gym
So some of you might have already heard about The Gym in Maseru. Nicer than most private gyms in the States, and certainly nicer than the government hospital across the way from it, the Gym looks like it was built on another planet and landed by mistake in this small African country. We signed up for the Gold Membership the other day. For a whopping 19 US dollars a month, you get weights, heated pools, treadmills, bikes, elliptical machines, rowing, squash courts, ping-pong (YES!! - oops, no nets), etc. We passed up the Executive Membership which adds the dry sauna and steam room. As much as I enjoy these normally, we decided that in a country with one of the highest rates of tuberculosis and enough extensively drug resistant TB to attract Paul Farmer’s Partners in Health group to start a project here, it’s best to avoid cramped, small, damp, enclosed spaces filled with near-naked Basuto men coughing into your alveoli. We also saved 5 dollars a month with that decision. Learned to play squash (like racquetball but with a ball that looks like it should bounce but doesn’t; the game is named after the noise that’s made as you run into the plexiglass wall at the back of the court). The Basuto male members are all large. That is, the men that go to the gym are built like tug boats. I doubt that any of them are traditional sheep herders; if they are they must carry their sheep from town to town.

Work
Most of the days this week have been spent filling out paper work. Proof that I am a doctor, proof that I haven’t been arrested, questions about my plans for work in Lesotho, questions about how many wives I am bringing into the country (I need special permission from the government for more than one!). We’re getting to know the ropes around the clinic through lectures and a little shadowing. The clinic is new and nice. Yes, the rumors are true – the medical records are electronic, typed during the clinic visit on these box-machines called “computers”, for my friends at the Santa Rosa Family Practice Clinic. Believe it or not, we have social workers, in-clinic pharmacist and pharm techs (that can compound meds, do pill counts, alert us if they think there are adherence issues), nurses that go into the community to find patients that have missed appointments, real, live, translators whose job is to translate (instead of also be a nurse or clerk, and no freaking AT&T translator phones), a classroom for lectures (with built in computer and projector hardware), wireless internet (fast), dial up internet (slow), a small library, local artwork, a lunch room, etc. Clinic starts around 830 am. The day begins with the staff and some patients singing harmonized hymns (they’re amazing; I’m making some recordings on my iPod and will send some soon). Some of the kids come in very sick and have to be coded in the treatment room. Most look and are relatively healthy. Many of the kids around this clinic that need to be on antiretroviral medications are on them. The waiting room is crowded but not pandemonium. The patients come en mass in the early morning without individual appointment times and are seen in the order they are registered, except for those discovered on triage that are very sick. There is “Family Clinic” which means adults, 90% of which are women, lots that are pregnant. We provide the prevention of mother to child transmission care to the pregnant women, prescribing and managing their meds, etc. They continue with their midwives/obstetricians for routine antenatal care and deliver either at home or at the hospital with those same providers. Perhaps unsurprising to some of you, I’ve started to see what opportunities there are to get involved with actually catching the little wet willies when they’re born. We’ll see. Otherwise, work looks like it will be divided between the main Baylor Center of Excellence (COE) in Maseru, the run down government hospital wards at Queen Elizabeth 2 (aka QE2, or Queen 2), QE2’s own pediatric HIV clinic, and then work outside of the city. This community work sounds great - road trips or small plane trips to the mountains, past mesas and waterfalls, to set up pediatric HIV clinics in hard to reach areas around the country. Teaching opportunities abound, from training med students and residents from the US that rotate through Maseru, to lecturing to doctors and nurses in India about pedi HIV care, and lots in between. Of note, I haven’t yet found a group, whether government or a non-governmental agency (NGO), that is actively working with the sex workers in HIV prevention and treatment. With the successes seen in places like Thailand and India, I would be surprised if a program has not been implemented to help with this marginalized and stigmatized group. More on this as it develops.

That’s all for now. Hope you are well. Keep those emails coming.

In The Beginning

2007-09-14T04:42:00.000-07:00

8/14/07

Greetings and salutations. Welcome to the beginning of (and longest entry to) my internet journal of my travels in Africa with the Baylor International Pediatric AIDS Initiative (BIPAI), as part of the Pediatric AIDS Corps (PAC). I am currently a few thousand feet in the air, above what is either Botswana or northern South Africa. We’re too far up, so while I can see the browns and greys of an arid landscape below, I have to squint my eyes and fire up my imagination to see the herds of cape buffalo and zebra. My long time friend Anu Agrawal, who I’ve known since medical school and has recently graduated from the Children’s Hospital of Oakland pediatrics residency and joined the PAC, is sitting a few rows ahead of me, possibly reading, sleeping, or watching the Disney cartoons that are showing on the plane’s teleprompters (the sun has just risen on the 2nd of two red eye flights we’ve taken in the last 40 hrs). We’re nearing the end of a long trip that started in the morning of 8/12/04.

Graduation and travel home
To take a few steps farther back, I graduated from family medicine residency on July 1st, with a beautiful ceremony at the Trentadue winery in northern California, attended by the Pierce clan. After packing up and saying goodbye with a heavy heart to my friends, the Russian River Brewery, and the hot tub, my brother David and I squeezed into the Element (The Toaster) and made a 3 day journey to Texas. With scenic views, including Route 66 and the Grand Canyon, we made it home without any mishaps (and somehow still as friends). After a week in Corpus Christi, catching up with my family, I packed up again and drove to Houston to begin the PAC pre-service training.

The PAC is composed of about 50 doctors, mostly pediatricians, but also including medicine/pediatric doctors, family doctors and and a few internists. Many of us have just graduated from residency, a few have recently completed fellowships in hematology/oncology, cardiology, or masters of public health, and some have been out in practice for a number of years. The PAC’s mission is to provide quality, compassionate care to children and their families affected by HIV/AIDS in Africa. It begun only last year, as a way to staff the clinics that have been built through BIPAI in the African countries of Botswana, Lesotho, Swaziland, Malawi, Burkina Faso, Uganda, Tanzania, and most recently Kenya (I have a feeling that sites on the horizon are Namibia and Mozambique). Funding for the clinics and for the PAC is through a combination of contributions from the local African governments, Baylor College of Medicine (BCM), and the philanthropic branch of Bristol-Meyers Squibb, among others. Of the 52 docs that were placed on the ground last year, around 30 are staying for a second year and that means there are around 20-24 of us newly assigned PAC docs this year.

Wednesday, August 15, 2007

I’ve now safely arrived in Maseru, the capital of Lesotho, and am writing on my laptop in bed while accessing the wireless internet from the clinic across the yard. Before elaborating on that, I’ll catch up a little on how I got here.

Houston
The training in Houston, which began 2 weeks after residency graduation, went well. They put the 2 dozen of us up in the relatively fancy Marriott Resident Inn in downtown Houston. Ahh, Houston. I had forgotten all the wonderful things it boasts: barbeque, roaches the size of small mangoes, 100% humidity, 90 degree weather, aggressive homeless folks, traffic, hmmm, what am I leaving out? OK, to be honest, I loved getting back to my favorite haunts – the Gingerman (great bar) and Rice Village, Istanbul Grill, Balaji Bhavan (south Indian cuisine) and seeing some old friends. The first weekend brought my family medicine boards (2 more weeks till I get my results...). Monday through Friday we sat in lecture, mostly covering HIV, TB, and tropical disease. We worked in small groups on case assignments, did a little lab time, and filled out a ton of paperwork necessary for working and living abroad (taxes, insurance, shipping, loan repayment, canceling your cell phone, arrangements with your bank and car insurance, etc). It’s amazing how much stuff is involved. The prime minister of Lesotho dropped by Houston on his way from speaking with Bush about HIV in Lesotho. We had a fancy lunch with him, part of his cabinet, and lots of serious looking buff guys in suits with ear pieces. I got to speak briefly before him and the delegation about how excited we all were to get started in Africa. The local NPR was there and did a little story on it. (http://www.kuhf.org/site/News2?news_iv_ctrl=1521&page=NewsArticle&id=21102)
The PAC group looks great – compassionate, funny, talented people. I feel very lucky to have the chance to work with them. We bonded quite well during our time in Houston. While we were excited to head off to our respective sites in Africa, it was hard saying good-bye to those that will be many miles away in other sites. We met two other docs that were doing the training with us but that weren’t going to Africa through BIPAI. Katy, a long time pediatric ER physician, has worked for Doctors Without Borders for many years. The other, Jen, has been out of pediatrics residency for only a year but is traveling though Physicians for Peace to Eritrea (near Ethiopia) to help start the country’s very first pediatrics residency.

Germany
I drove back to Corpus for two last nights with the family. They saw me off at Corpus’ little airport, where I flew to Houston and met up with Anu. We took the 10 hour flight to Frankfurt, Germany, where the men are tall and the women are taller. Wow, there is a plethora of attractive, beer guzzling women that would make quick work of me if I cut in front of them at the line to the bar. One of my first sights at the Frankfurt airport was a large group of Orthodox Jews in full regalia, bobbing while praying and facing one of the walls in the terminal. It took me a second, but I realized how wonderful it was to experience what was impossible to see only 60 years ago.

Maseru, Lesotho
So since most people will have given up reading by this point, I will keep this short for you die-hards. We arrived in Johannesburg (Joburg, as is hip to say; you’ll look, sort of, like a local, if you do this) without trouble and rushed through customs, grabbing my baggage and getting into the tiny terminal for those going to Lesotho. This plane was a little puddle jumper, room for about 30-40 small legged people and one short (required) stewardess. We stepped out of the plane around noon and were greeted with amazing, very non-Houston like weather – mid 50s, sunny, clear and crisp. The landscape is gorgeous, like a mixture of Joshua Tree National Park, Arizona and New Mexico. We’re in the end of winter here, with most days in the 50s and nights in the 30s (tonight the expected low is 18F). One PAC guy that’s been here a year complained to us that it wasn’t overcast and rainy enough for him. After wintering in Santa Rosa, I’m ready for some dry winter days. We were greeted by Dr. Edith Mohapi, the clinic director whose husband is the Minister of Finance (nice people to have in your cell phone for emergencies). Driving on the left side of the street in a car with the steering wheel on the right (wrong) side and the shift on the left (wrong) side is a little weird, but I think I’ll get used to it. We’re temporarily staying in the “cottage”, the living quarters built on the clinic campus for visiting docs and med students. Cindy, Kevin, Dewey and any others who had the pleasure of staying at the Casitas Verdes at the Hospitalito Atitlan in Guate will see no relationship between them. Steaming hot water shower, fridge, washer/dryer, wireless internet, and a distinct absence of scorpions are some of the stark differences. Man, am I in Africa?

I already miss you guys very much. I do hope that I can convince someone to come out this year, though I know how busy it is, whether working the daily grind or getting through residency. It looks like I can entertain visitors whenever I want; clinic is M-F, mostly in town but some work in the rural parts of the country, some traveling for teaching seminars and meetings, and 4 weeks of vacation. Additionally, I’ve already started snooping around to see about elective opportunities. According to BIPAI central, most months for the coming year are filled for all PAC countries, but our clinic director says there's probably extra room for those interested. There is a government hospital in town that people occasionally rotate through, though Dr. Mohapi says that it’s understaffed, undersupplied, and you might be asked to do things out of your normal scope of practice. Don’t worry, Jim, I told her right away that I knew a few people that might find that somewhat entertaining. Luckily, there are better ways to get here. There is a direct flight from D.C to Joberg, then it’s just the 1 hr flight to Maseru. I’ll let you guys know more about working here after I actually start to do some myself.

OK, I’m out. Take care. Jake, do me a favor and say hi to the ladies in the clinic (Eugenia would never forgive me if I didn’t).

Jeff