Southern African Adventure

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

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

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

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

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

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

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.