Thursday, June 14, 2012

Epilogue -- What I Saw in Africa

            In 1922 G.K. Chesterton wrote the book What I saw in America, which was based on his recent experiences in traveling to America. Now anyone who has thought in any seriousness about human relations will know that it is next to impossible to truly convey an idea or feeling to another individual. The feeling that my experience of the world is more real or authentic than another’s is a major barrier in trying to get to know or understand another individual. In writing, this difficulty in trying to convey an experience or feeling or idea to an audience becomes magnified in the interpretations of the readers and failures of the authors. It is this very impossibility, however, that allows for the greatest writing to be born and perhaps more intimately for that rare occurrence of true Love.
            In this post I plan to attempt an explanation about one thing that I saw in Botswana. Do not expect from me, however, an accomplishment as worthy as that of Chesterton’s. It is not possible for me to do any kind of justice in my writing to what I experienced this past semester in Botswana. The overall experience was something so unique that even those who joined me cannot truly understand my own experience. Still, it is possible for me to convey to you some of what I learned. In talking with my fellow students, there was one idea about the culture of Botswana that seemed evident everywhere and led to so many other cultural nuances that we observed. This was the idea of ‘Botho.’ The word ‘botho’ translates roughly to English simply as ‘respect.’ The idea of Botho is summed up in Setswana by the words ‘motho ke motho ka batho’ or ‘I am because you are.’
 It does not take a long time of living in the country before one realizes the vivid veracity of this proverb in Batswana society. The idea that individuals in a community are not as important as the community itself, or that the community defines individuals themselves is permeated throughout the society. Because of this, one finds that most people are extremely friendly and willing to help a stranger in a heartbeat. Even more interestingly, I found that there has been a shift in how this virtue is lived out when comparing the younger generation to that of their parents. Especially in the city, society is becoming more industrialized and more business oriented. As this happens, one sees a shift away from the community importance and more toward the individualism more commonly seen in countries like the U.S. While this shift cannot be ignored, the history and current presence of Botho has not been completely driven out of the city, however. If you are lost on the street and ask a local for directions there is a good chance that she will walk you to your destination herself without the slightest want of repayment. This shows the respect that can be seen for all people as part of the community. 
              In the villages however, this becomes even more apparent and an even more integral part of everyday life. During my village homestay in Serowe, our family would usually have someone drop by in the evenings. It is expected when this happens that the visitor joins the family for dinner. My host-sister told me that this is commonplace in the village. If she does not have food one day, she will simply walk to her neighbors and it will be provided without question. In addition, everyone is recognized in the village. There is no anonymity that comes so inherently with being in the city. As visitors, my friends and I would sometimes be a spectacle on our walk home, as children would commonly show off their homemade toy cars (made completely from scratch) and ask to take pictures with us. The smiles were unceasing. In the Spirit of Botho, when it was time for our group to leave Serowe, my family selflessly slaughtered a cow for the farewell celebrations. In Botswana, cattle are a main source of livelihood for some families, and always a symbol of status. For my family to do this for the group shows the respect they had for us. Everyone was thankful that our lives were connected in the unique ways in which they were. The smiles were unceasing.
            Since coming back to the U.S., people often ask me if I saw a lot of poverty during my time in Africa. It is true, especially through our healthcare experiences, we saw people in distress, in fact we saw people in devastation. We saw people who didn’t understand how to lead a healthy lifestyle. We saw people with struggling businesses unsure of their future livelihood. And we saw people who could hardly afford to keep their children healthy. Sure, we saw poverty—but I can find poverty even in the U.S. In Botswana, however, we also saw Botho, we saw a culture that has been founded on the idea of respect for all people as members of their society. So when people in Botswana would tell me that they want to come to America, as often as I could I tried to tell them: “Yes, great things can be had in America; but don’t forget about what you have, don’t forget about Botho.”

Sunday, June 3, 2012

Final Reflections from Botswana

“How do you pick up the threads of an old life? How do you go on, when in your heart you begin to understand, there is no going back?”
            Perhaps my experience this past 5 months has not been quite so dramatic as the epic Tolkein tale, however I find it fitting to conclude this exploration of my experience in the same way it began. Despite the degree of drama, there is no doubt that the last 5 months have been some of the most important of my life. They have helped me to better understand myself, and my place in the world. But how can I describe to you what I have learned? There are 3 areas in which I believe I have greatly grown through my experience abroad. These include: career, personal, and spiritual.
            I will begin with what was the initial stimulus for choosing to study abroad, career goals. I set off for Africa thinking that I needed to understand medicine and healthcare better, and in a much broader sense in order to truly understand if this was where my calling lay. My doubts about this were perhaps answered most emphatically of all my doubts in entering this trip. In living with other Americans who had similar doubts and similar ambitions as myself, I was able to have some of the most in-depth conversations about medicine in which I have ever been involved. In addition, observing and being involved with care in the setting of Botswana, and being immersed in the Public Health issues of the country was of an almost indescribable benefit to me and to my fellow students.
There was a point, I would say somewhere around half-way through the semester, where I decided that I wanted to be a doctor. I decided I am ready for medical school and I wanted to be the one treating patients, not simply watching. Unfortunately, I also realized that I still have another year of undergraduate school left, and the stress of applying and interviewing for medical school, and choosing a school before I can think about this truly becoming my life path. However, I know now more than ever where my conviction lies. Especially when I compare this experience to my time in the lab at UNL. For much of my time at UNL I have been fairly immersed in the research branch of science. I have spent 3 summers working full time in a lab, while spending the semesters working part-time. My experience in Botswana was the first time in my life that I have truly been immersed in medicine, at least to an extent that I have never before experienced. This has allowed me to compare my interest in the two. I found that my passion is in medicine. My passion is in talking to suffering patients and helping them to relieve that suffering. My passion is in being intimately involved with the emotions of people, while understanding my right place in guarding myself against that intimacy. My passion is to be a doctor. It has become more and more clear to me that the fulfillment of these passions will come, at least in part, in medicine. While I have found this to be true, my experience in research remains as one of the most valuable of my college life, and will surely be of vital importance as I begin a career in medicine.
            How should I be in relation to others? What is my place in the world? Ultimately, I guess this question is ‘who am I?’ While I am still in search for the true answer to this question and perhaps a final answer is unattainable in this life, I believe I have moved forward in my search for the answer. The writings of Thomas Merton and James Orbinski were perhaps two of the most influential authors I have read in my life, and ironically their books happened upon me during the most influential experience of my life. Thomas Merton lived during the 20th century and grew up in the absence of religion or spirituality. As he realized the emptiness of his life, he grew to understand the importance of spirituality and eventually entered a Trappist monastery and took a vow of silence. While I don’t believe I have the same calling as Merton, his writings helped me to understand the importance of spirituality in forming your true self and in being true to those around you. While I have always understood that doctors carry a great responsibility due to the immense power that is put in their hands, I think this fact became explicitly clear during my time in Botswana. This was not through any specific experience, but through the composite of my experiences, conversations, observations, and studies. Because of this power, I have come to realize that it is more important than I had ever imagined for doctors to truly understand themselves before they can think about helping people. I know now that I must determine that which is most valuable to me, and hold these values through the thick and thin of medicine. Without this, I will surely lose sight of my responsibilities as a doctor. These ideas have also been echoed in the late Bernard Nathanson who said: "It has been my experience that only those who have an inflexible inner spiritual column supporting the immense weight of medical obligations and responsibilities survive intact the lure of the worldly temptations in the medical world....without such an absolute guide to virtue, doctors, exposed as they are to greater temptations than most, are likely to fall further." The formation of this ‘inflexible spiritual column’ has now become of utmost importance to me.
James Orbinski was a doctor working for Doctors Without Borders/Medicins Sans Frontiers (MSF) during some of the most serious crises of our time. He also became president of the organization and accepted the Nobel Peace Prize on behalf of MSF. His book was called, almost too perfectly (pun intended), ‘An Imperfect Offering.’ In the book he describes vividly his experiences as an MSF doctor. Most notably, he worked during the UN intervention in Somalia in 1992 and then during the Rwandan Civil War in 1994. After describing his experiences, he goes on to discuss the problems facing Humanitarian work in the world today. The book is so titled because of the recognition that even amongst highly successful organizations such as MSF, the aid offered is far from perfect. It has become clear to me now that while I have adopted a somewhat more skeptical view of humanitarianism, work in humanitarianism has become a serious call in my life. As Orbinski described his experiences I began to feel that his work was serious medicine. While I recognize the need for medicine around the world and even in my own community at home, the work done by Orbinski seemed of the utmost importance. While it is possible for me to do this, I believe that it is my duty as a humane caregiver to be involved in providing access to care in places that have been deprived of this privilege. I am sure that my understanding of this area of work will become clearer to me as I work through medical school. Finally, on this topic, Merton advises: You cannot tell me who I am, and I cannot tell you who you are. If you do not know your own identity, who is going to identify you? Others can give you a name or a number, but they can never tell you who you really are. That is something you yourself can only discover from within.”
I believe I may have more to say on these subjects, and if I feel it is appropriate, I may update this post with more reflections on my revelations from abroad. This post is perhaps the most personal thing I have ever made public. I hope that whoever reads it finds what I have said informative or perhaps even inspirational. I hope that anyone considering studying abroad may find this blog as an invaluable resource of one person’s experience. I have done my best to lie out an honest evaluation of my experiences. At times I have failed to keep the blog regularly updated and I have not been completely satisfied with any of the posts, but I have found that in writing I have been able to reflect much more seriously than I ever could have without. If nothing else, I hope that perhaps my words and pictures have brought a smile to the faces of a few.
I now, finally leave you again with a poem out of, yes the Lord of the Rings. I think the plight of a searching college student could not be put more beautifully than in the following words, written by J.R.R. Tolkein:

The Road goes ever on and on
Down from the door where it began.
Now far ahead the Road has gone,
And I must follow, if I can,
Pursuing it with eager feet,
Until it joins some larger way
Where many paths and errands meet.
And whither then? I cannot say

Tuesday, May 29, 2012

Traveling South Africa -- Cape Town

          After our return from Durban, our remaining time in Botswana began to draw to its close. The end came in sight, and the reminiscing and goodbyes were anticipated. In the midst of all this, we still found time for travel. The testing period at UB lasts nearly 3 weeks, and several of us were done within the first couple of days. Because of this, we took advantage of our time, and arranged a final trip to Cape Town, South Africa. This time, our mode of transit would be Combi bus to Johannesburg and then we would fly to the southern most part of Africa and arrive in Cape Town. As is our custom, we would not make the trip easy. Since we have been living in Botswana for over 90 days now, it is has become necessary for us to carry travel waivers when we cross borders. However, since this hasn’t been necessary for most of the semester, we did not really think about it on this trip. Unfortunately, one of the students traveling with us lost hers, and was held up at the border. They told her that she would have to return to Botswana, and pay a P100 fine for each day since her study visa expired (around P1000). The rest of us had to continue on with the bus, as our tickets were non-refundable and we had a flight to catch that afternoon. The story of how this worked out is not quite mine to tell, and I cannot quite capture how miraculous it was. The girl returned to Botswana, convinced the officer to reduce her fee in half, hitchhiked from the border to the airport in Johannesburg and arrived at the airport even before our own bus. My apologies for the terrible summary of an amazing story. Anyway, our first hurdle of the trip was under our belts and we boarded our plane for the beautiful city of Cape Town. We took an overpriced cab from the airport to Long street, which is the central downtown street of Cape Town and also the home for a large number of hostels. After spending over 30 minutes driving up and down the street looking for the hostel, we finally arrived at our destination. We spent the next few hours catching up on sleep, and then set out to explore Cape Town.
            Our first adventure in Cape Town, was advised to us by some friends of ours that had visited Cape Town earlier in the semester. This was a ‘restauraunt’ although that may not be the correct word. It was in a rather run down neighborhood on the outskirts of Cape Town. The place is called Mzoli’s. The way it works is as follows: you wait in line until you arrive at a counter filled with raw meat of all different kinds, you then tell the people what kinds of meat you want, then they season it and give you a large plate of raw meat, finally you take the meat to the smoky oven room in the back where at this point there were already nearly 200 plates in line to be cooked. Because of this, the wait for the food  to be ready is around 2 hours. In the meantime, there is a tent set up around the corner with music and a dance scene. After the long wait, we enjoyed some of the best braii’d meat I have had in Africa (and Africa knows how to braii). The club began to close down at 8pm, and we finally journeyed back into town.
View from Table Mountain
            The next day we hiked Table Mountain. Although the weather did not cooperate, the views of the city and the surrounding mountains were spectacular. About half way up our hike, we began to enter into a low-lying cloud. Before long, the wind began to pick up speed, and we became encompassed by the cloud. Unfortunately, we had to turn back before reaching the top of the mountain, due to the severe conditions. As we reached the bottom of the hiking trail, the rain began to pour down. Our already moist clothes were soon drenched from the downpour. We walked for about a half an hour through the rain before reaching the welcome center, and catching a cab back into town.
            Later that day, we booked a wine tour for the next day. This would run from around 8 in the morning until 8 in the night. We were picked up in the van that would take us around the greater area of Cape Town throughout the day, and continued on to pick up the other groups that would be touring with us. The first place we visited was a family owned vineyard called ‘Villiera.’ At this vineyard, our tour guide walked us through a field of grape vines, and explained to us the process of making wine. Between our lessons, we enjoyed some of the wine and champagne made by this small family business. Throughout the day we would taste wine at 5 different vineyards. In the process we were able to explore the area around Cape Town, which consisted of some of the most beautiful landscapes I have seen in my life. I will leave my unsatisfactory pictures to explain the beauty. By the end of the day, we were all feeling the effects of the wine, and had one of the most exciting days of our trip under our belt.

            Our next adventure would be a trip to Robben Island, which houses the prison where Nelson Mandela was imprisoned for his involvement in the anti-Apartheid movement. The prison has now been turned into a memorial to the prisoners who were held here and stood up for their freedoms. The tours are guided by ex-prisoners, which give them a uniquely personal aspect. Our tour guide had spent 5 years in prison, and told us that of the 5 others that entered with him, only 3 survived their imprisonment. During the tour we were shown the cell that housed Nelson Mandela, as well as the courtyard where Mandela had kept a garden. The tour guide told us about the brutal conditions under which the prisoners were forced to live. The experience was one that I will not soon forget, and provided a rare glimpse into the infamous racial issues that still exist in South Africa today.
Camps Bay Beach
            After we returned from Robben Island, we took a cab to one of the popular beaches of Cape Town. Unfortunately the weather did not provide us with a good day on the beach. Still, we braved the cold and explored the rocky beach, which had a special view of ‘the 12 apostles’ which is a nickname given to the 12 cliffs that provide the backdrop to this beach. After what seemed like hours of hopping through the various rocks that protrude into the ocean and collecting rocks and shells, we finally headed back to the hostel after a long day.
            Before long, our time in Cape Town had come to a close and it was time to head back to Botswana, where we would have 1 day to prepare for our final program trip to the Okavango Delta. The next morning we planned for a cab to take us to the airport, where we again flew to Johannesburg. In Johannesburg we caught a Combi back to Gaborone, and returned to school. 

Nelson Mandela's cell

A view of Cape Town from Robben Island

The 12 Apostles
Mountains in the Cape Town area, seen on wine tour
Our final vinyard

The group

Sunday, May 27, 2012

Traveling South Africa -- Durban

In the month of April, I took two trips to South Africa. The first was to the city of Durban over our Easter break. This city is on the southeastern border of the country on the Indian Ocean. The second was to Cape Town, which is on the southwestern border on the Table Bay, a natural bay of the Atlantic Ocean. As is always the case with my travel crew and I, we had some rough beginnings, lack of planning and amazing experiences together.
            Our trip to Durban began on the Wednesday during Holy Week. Since we were technically still in school, some of us still had things to take care of before we could leave Gaborone. We scheduled a bus out of Johannesburg, SA that would leave at 10pm for Durban. We caught the last Combi out of Gaborone that left around 4pm. The problem with these Combis is that they do not run on a set schedule, rather they simply wait until they are filled and then set off for their destination. Because of this, we were cutting our   time to make the bus very short, since it takes about 6 hours to get to Johannesburg. Around 8pm, we were stopped at a filling station, and we told the driver that we were trying to make a 10pm bus out of Johannesburg. He anxiously looked at his watch, then told us that we would make it, and proceeded to rush everyone into the Combi. We entered the city around 9:15pm and thought that we would make it in plenty of time. Unfortunately, Johannesburg is a tremendously spread out city and we were still no where near the bus station when we entered the city. Soon we realized that the driver was driving excessively fast, and practically ignoring stoplights. It didn’t take us long to realize that he was doing all this in order to try to get us to our bus on time. After turning the bright lights of Johannesburg into a blur, and yelling at several passengers to hurry out of the Combi at their respective stops, we ended up at our bus at exactly 10pm. We thanked the driver for his efforts, tipped him and hurried off to our bus. After arguing with the new driver about our tardiness, we were finally let on the bus, and on our way to Durban.
Looking down on our hostel

            We arrived at our hostel at 6am the next day. Our hostel was about a 10 minute walk from the beachfront and located on the second floor of a multiple purpose building. The lobby of the hostel has no roof and is surrounded by walls that stretch about 4 stories high. Having had very minimal sleep on the bus, we decided to take a nap before beginning our day. After several hours we woke up and walked down to the beach front to see what we were in for. The first thing we noticed about Durban is that the area of the city on the beach is a rather run down section of the city. Trash is littered on the streets and sidewalks and the buildings are all very unkempt. The beachfront, however, is beautiful. The boardwalk was packed with people and tourists enjoying the warm sun and surfers and swimmers were scattered throughout the water. After eating breakfast at a restaurant on the beach, we walked along it for a while and sat down on one of the cement slabs that line the city-side of the beach. After taking in the view, we were ready to leave, when my friend realized that her wallet was missing. We searched high and low for the wallet, but finally had to accept that it had been stolen right from under our nose. Again, it wouldn’t be our vacation without beginning with some hurdles.
            Our experience in Durban was one of enjoying the company of our friends in a beach town that seemed to have seen its better days. Since most of us at this point were conserving cash, we opted away from some of the more touristy options such as shark cage diving or snorkeling. Instead we spent most of our time on the beach, and exploring the various shops and vendors along the area. We also visited the aquarium, which is apparently the largest aquarium in the Southern Hemisphere.
 After several days on the beach and exploring the nightlife of Durban, it was time to return home again. Our bus out of Durban was leaving at 10pm and was supposed to arrive in Johannesburg. Soon after our departure, however, the bus began having mechanical problems and we found ourselves broken down on the side of the road, only about an hour outside of Durban. After several attempts to fix the bus moved us maybe 30km farther in our journey, they decided to send another bus (from Johannesburg) to pick us up. We waited for hours longer in the parking lot of a gas station. The timing of everything has become rather blurry, but after we finally arrived in Johannesburg, it was about 3 in the afternoon. After that we had to catch a combie back to Gabs, which is another 6 hour drive. All in all, our journey turned into an unnecessary 24-hour endeavor. But, alas, we had arrived back at school and returned to life in Botswana. 

Thursday, April 26, 2012

Clinical Reflection from Gabs

Here is another journal about some experiences and reflections of the clinic in Gabs. It picks from several points throughout the semester. Enjoy!

Since my last journal about my experiences in the Broadhurst 3 clinic, in Gaborone, I have learned many things. On February 31st, I shadowed the ARV doctor. This was my first experience of shadowing a doctor in Botswana. Since one of my main areas of interests in the humanities is the ethical issues surrounding patient autonomy and the doctor-patient relationship, I was excited to begin learning about this in Botswana. The doctor I shadowed on this day was a quiet man from Ethiopia, who gladly welcomed me into the consultation room. Most of the patients he saw on this day were people who were returning to refill their ARV medication. The basic procedure when this is done is as follows: the patient will come in 2 or 3 days prior to consultation, to have his or her blood drawn, then the patient comes in to see the ARV doctor and review the current status of the disease. The basic points of concern from the blood test are CD4 count and the viral load. Mature helper-T cells express the CD4 membrane protein and are referred to as CD4+ helper-T cells. The CD4 count measures the concentration of mature helper-T cells present in the blood. The viral load measures the amount of detectable HIV virus in the blood. Patients enter the consultation room and hand the doctor their identification card and patient file, and the doctor begins analyzing the blood test. If the patient is just beginning ARV treatment the doctor will ask if they have any questions about the treatment. At this point, the patient will have already undergone counseling, and the doctor is simply following up to make sure everything is clear. If the patient is returning for continued treatment, the doctor will explain the results and discuss the status of the current disease.
            My first impression of this entire process was that it is very technically sound, but personally detached. The doctor that I was shadowing on this day did not seem to take any particular interest in the patient. Rather, he was immersed in the test results, and very much focused on the numbers on the paper he was interpreting. While this in itself is not a bad thing, in my opinion the separation from the patient is a problem in the field of medicine. It is true that every doctor (or provider) is an individual and will have a unique way of addressing patients and handling daily duties. Still, the problem at hand is a real one, at least for those who still hold the art of medicine—as compared to the science—as valuable. The struggle to find the correct balance between the art and science of medicine is one that is far from new and far from being resolved. In the real world of practice, it can be extremely difficult for patients to get the time and attention they deserve. A Cuban doctor we spoke to in Serowe echoed this problem, describing a Cuban system that was almost facing the same trouble at the other extreme. In Cuba doctors are penalized for ordering too many negative tests. This forces doctors to be much more hands-on, obtaining from the physical examination the most possible information. It has been my conviction that the straying from the physical examination as the primary tool of a doctor is one of the greatest problems in medicine. My experience in Botswana has confirmed this as a threat not only to American medicine, but also to medicine worldwide.
            My next experience in the clinic was with the general doctor. Here patients presented with all sorts of different ailments, including: sexually transmitted infection, tonsillitis, chronic hypertension, asthma, and skin irritations. This is a pretty standard list, with not much difference of what one might see in the U.S. I have found it interesting that hypertension and diabetes are major health issues, in this country, since obesity does not seem to be one. Interestingly, I was told that the diets here are very high in starch and energy. I have noticed this as well in my own experiences. The main dish at nearly every meal is overly large portions maize or sorghum based porridge, which are exceedingly high in energy. On campus, the snack item of choice is a fat cake. This is basically deep fat fried homemade bread, and is made in mass quantities at every cafeteria.
            In addressing these problems, the doctor told me that he is required to process each patient through quickly. He even mentioned that he has been warned by the Ministry of Health for spending too much time on individual patients. As a result, he was very quick in his work, and very quick to prescribe medication. This is another major problem that I have noticed in every clinic I have been to. Prescription of antibiotics and painkillers is given with alarming ease. If a patient presents with an infection of any sort, antibiotics are prescribed immediately. As is well known, the effectiveness of antibiotics is diminishing quickly, in large part due to over prescription by providers. The doctors here do not seem to recognize this, and do not even counsel patients on the vital importance of adherence to these drugs. This doctor was also very quick to refer patients when they seemed outside his ability to treat. For example, one patient came in with an eye irritation, and without even being examined; the patient was referred to another doctor, since the eye seemed to be an area off-limits to this doctor. A similar situation arose many times, and I was surprised that the doctor was so quick to move the patient along, without even performing an examination. As mentioned, this is part of the requirement of his job and is, unfortunately, an expected outcome of dealing with a heavy patient load and minimal personnel.
            Since returning from our visit to the village of Serowe, I have visited the clinic twice. The first time, I returned to the ARV doctor, to continue learning about treatment of HIV/AIDS. The doctor on this day was from Zambia, and had a much different personality from the first that I shadowed. Before, I assumed the language barrier prevented the doctor from meeting the patient on a level suitable for intimate discussion. The Zambian doctor I shadowed this time around, however, was very sociable and managed to get the patients to open up much more than before. He was able to understand when a patient was holding back, and find the right words to make them open up to him. This gave me confidence that while patients prefer to speak Setswana when discussing such important things, many are still able to communicate effectively in English when the doctor is able to take control of the conversation. This is especially true in the city, Gaborone.
            I also gained many more insights into how ARV treatments are delivered. One young woman came in who was fighting tuberculosis. When an HIV-positive patient is also infected by TB, ARV treatment is started regardless of the CD4 count. This means that the patient will have to remain on ARV treatments for the rest of his or her life. This is especially unfortunate in a young person, since treatment is not to be stopped once it has been started. Since there are only two lines of treatment available, this increases the patient’s chances of becoming resistant to both lines sooner. One of the main challenges of ARV treatment is to make sure the first line of drugs lasts as long as possible. Once the patient begins to resist these, treatment becomes exceedingly difficult.
            In many cases the antibiotic cotrimoxazol (CTX) is given as a prophylaxis against opportunistic infection along side the ARV treatment. However, this antibiotic has many severe side affects and cannot be given to every patient. When it is not given, the patient is at an increased risk of acquiring an opportunistic infection. Prescription depends on the health of the liver, as determined in the blood tests; as well as by the overall health of the patient. The ARV doctor must account for both of these in discerning whether or not this antibiotic ought to be prescribed.
            I also learned that the Ministry of Health would soon be increasing the CD4 count required to receive ARV treatment. At the moment, the count is <200cells/uL, the change will increase it to <350cell/uL. The positive side of this is that patients will be able to start treatment before the HIV virus has begun to attack the immune system so seriously that it is hard to recover. However, from the perspective of the medical system, the patient load will be dramatically increased, while the personnel numbers will struggle to keep up. In addition, patients will begin treatment at a younger age, increasing the likelihood of becoming resistant to the ARV medication.
            Interestingly, I asked this doctor to compare the medical system in Botswana to his experience of the one in Zambia. He told me that when it comes to treatment of HIV, Botswana is much more advanced. For example, in Zambia the viral load is not even considered in ARV treatment determining how to organize the ARV regimen. While praising the free system, he also warned that a host of problems also follow with the system of free care in Botswana. Many of these have been described in this short reflection.
            My final conversation with the ARV doctor was about the reasons for the success in lowering the rate of new infections in Botswana. In addressing the culture, he gave two things that have allowed the campaign to be successful. First was the decrease in the taboo on talking about sex. He told me that patients today are open to talking about issues revolving around sex. They now understand the importance of these conversations, especially in the health field, and are willing to do what is necessary for their health.  Along these lines, patients are also much better informed now. Since patients are better informed about the nature of HIV and ARV treatment, they are better at taking necessary steps in their lives to treat or avoid HIV. While this is not universal, the sentiment is beginning to spread strongly throughout the country, and is allowing for the fight against HIV/AIDS in the country to take a turn for the best.
            My final experience, thus far was with both the HIV-testing clinic and then again with the general doctor. I arrived at the HIV-testing trailer in the morning, but the line was not very long. I assisted in the testing of several patients before the line dwindled. Even with all of our immersion in the problem of HIV in Botswana, it is still startling to see someone find out for the first time that he or she is positive. On this morning, I witnessed this happen to a man from Zimbabwe. The man claims to be faithful to his wife, but does not use a condom when sleeping with her. Unfortunately, since he is not a citizen of Botswana, he is unable to receive free ARV treatment. The counselors rattled off the practiced speech about finding a trustworthy person to discuss his situation with, as well as the importance of urging the wife to be tested. While this man was clearly surprised by the results, he was not very inquisitive; and beyond simple questions, the counselors did not make a rigorous effort to really understand and inform this patient, who had just been given life-altering news.  
            Once the testing clinic became stagnant, I moved to the general doctor. This doctor was from Ethiopia, and had been trying to find a job in the U.S. for some time. He has taken all of the required licensing tests, and has been attempting, unsuccessfully, to obtain a hospital residency position. His reason for desiring this was the opportunities that are opened up from having residency training in the U.S. “You can practice anywhere in the world,” he told me.
 Since my time with him was short, we did not see many cases. One interesting case was a woman who showed signs of an STI. The doctor told me that it could be caused by any of multiple organisms and, without a lab test; it was impossible to identify the source. As a result, it is necessary to prescribe several different antibiotics to fight several types of infection. This returns me to my point made above about the over prescription of antibiotics. The doctor did not seem to see any danger in prescribing this many antibiotics to one patient.
            My experiences thus far in both Serowe and Gaborone have been invaluable. Through these, I have come to a better understanding of healthcare in Botswana, as well as how the HIV pandemic is being treated in one of its hottest spots in the world. Learning about treatment and the nature of HIV in this country provides a giant window into this disease, which has devastated countless people’s lives all over the world in such a short period of time. Beyond this, I have also been able to reflect on the nature of medicine, and my own desire to pursue a career, and life in medicine. My conviction that this is the proper course for me has never been stronger. 

Friday, April 20, 2012

Traveling Namibia

          I have been the lucky participant in several travels around southern Africa recently. Unfortunately, I have been evading the writing about my trip to Namibia, for reasons uncertain to myself. Since it has taken so long to write, my detail will most likely sub-par relative to my usual style. In addition to Namibia, I also recently took an equally eventful trip through South Africa to the coastal city of Durban.
          There are so many great reasons for choosing to study abroad in Africa. Even in the peacefully modern city of Gaborone, you see a part of the world that is quite different from any place in America. This in itself has provided platform for the once in a lifetime experience that I have been a part of. The ease of travel, however, is not an advantage. Travel is difficult, to put it mildly. To make things even more difficult, my fellow travelers and I are not the most organized planners. For myself, this is not a major problem as I am always open to spontaneity, but for some it can cause major stress.
           For our part, we did decide that we wanted to travel to Namibia a good while in advance. The equivalent of American ‘Spring Break,’ called ‘Short-vacation’ here at UB occurred in the last week of February and the first week of March. As the time for travel approached however, we were in the midst of mid-term tests and only vague ideas were put forth about our plans. We wanted to see the capital city of Windhoek, and then go to the beach where we were advised that Swakopmund is the best option. Several days before our departure, we purchased bus tickets with a company called AT&T (no relation to the phone co.). Prior to the morning of our departure, we arranged for a cab to pick us up at 7:30am, in time for our 8:00am bus. Unfortunately, the cab arrived early, and several of us were late in being ready. The driver was not happy, and claimed to have another customer to attend to, for which he had scheduled 10 minutes after our own pickup (clearly not enough time). As his anger grew with our lateness, he decided to leave us in the parking lot, as we had not yet all arrived. The seeds of our non-preparation had begun before our trip had. I immediately called another taxi driver, who had been very dependable in the past. In reality, I had no expectation that our new driver would use the haste necessary for us to catch our bus. However, he arrived in the extraordinary short time of 5 minutes, and drove us swiftly (and probably dangerously) too the bus station. Just as our luck seemed to be turning towards the positive, our back door was opened, and a car immediately drove into the door. There had been minor damage done to the other car, and door of our taxi was too damaged to close properly. We gave our driver our information, and promised to help as we could. Unfortunately, most taxi drivers do not have insurance, and the price was significant. However, we were willing to put our unfortunate start behind us and set off for Namibia. As we boarded the bus, we soon realized, that it would be a long 14-hour ride to Windhoek. The seats in this bus were not built for adults, at least not average-sized adults. I can only assume they are built for children. Although, here, these buses frequently carry adults. No matter, I settled into the back seat, nestled between two people much larger than I. Throughout the trip; we would have to switch when to lean back, since our shoulders were much too broad for our seats. Luckily I had my Kindle and was able to accomplish some serious reading to pass the time.
Entering Windhoek
           As we entered the country of Namibia, I quickly realized that it is the most beautiful and diverse landscape I have yet seen in Southern Africa. The city of Windhoek is in the center of the country, and is situated in a basin between the Khomas Highland, Auas and Eros Mountains. The scenery of the mountains and the German architecture make it a beautiful, albeit relatively small little city. We stayed here for one night in a backpackers hostel called the Cardboard box. While the name may not make it sound flattering, it was quite accommodating and helpful in assisting to plan further travel. We decided that we would take a combi to Swakopmund, and set up plans to rent a house for the week. We were able to arrange everything from the hostel, and soon found ourselves on our way to the beach!
Leaving Windhoek
           As we arrived in Swakopmund, we could already smell the beach before it was even in view. The bus dropped us off at a barren looking station, where Susan, the landlord of the house we were to be renting was coming to pick us up. After several minutes of waiting with our luggage, chatting with a security guard, and fending off taxi drivers, Susan arrived to take us to our house. On the way, she stopped off on the beach to give us a quick glance of its beauty. We took in the view and absorbed the fresh salty air, a special moment for a landlocked person like myself. We then continued on to our house, which was along the beach about a mile outside of town. The front driveway of the house had a clear view of the beach, although it was a brief walk to actually reach it. Our house was also very accommodating. There were enough beds for everyone, a living room, kitchen and showers provided. In addition, Susan drove us to the nearest grocery store so that we could stock up on supplies for the week.
          We spent the rest of our first day in Swakopmund hanging out on the beach with some beer, books, and great friends. In the following days, our time was filled with exciting adventures. We began by exploring the odd town a bit further. As I said, our house was about a mile down the beach outside of the town. We were able to easily walk into the city to find restaurants, bars, and casinos scattered throughout this small tourist town. The most striking part about both the walk in, and the town itself was the odd architecture. The buildings were far from anything else we had seen in Gaborone or any of the surrounding villages we had visited. The architecture was clearly of German influence but they also had a very modern style. The buildings simply did not seem like something that belonged in Africa, especially from what we had seen thus far. After exploring the town, we stopped at a restaurant that was set on the beach and enjoyed some delicious seafood. Being from Nebraska, I have never really understood the seafood obsession, however all of my friends are nothing short of passionate about it, so it was fun to join in their indulgence. The next day, we went quad biking in the Namib desert, which contains beautiful sand dunes very much alike to those seen in the desert of Tatooine (for any Star Wars buffs, this is a point of pride in the brochure).       We arranged this the prior day, and were picked up from our house by a man named Charles. Charles took us to the administrative office to cover financial and legal requirements, and then we were off to the desert. Being in the midst of the desert was an experience unlike any I have had before. In the
Sand Dunes in the Namib Desert
States, I have seen many beautiful landscapes, but the dunes of this desert seemed almost unreal, they were simply so different from anything I had ever been exposed to in my life. Riding 4-wheelers through these dunes was also exciting. The traction in the sand makes the ride completely different from anything I have expereienced in the fields of Nebraska. We also were able to sand board down several of the major dunes in the desert. This simply involves waxing sheets of plywood and sliding down the dunes on your stomach. After three hours of excitement in the Namib, our time was up and Charles led us out of the desert, and returned us to our house. On our drive back, Charles also mentioned the possibility of skydiving. One of my friends had done this once before and immediately was ready for round 2. After two others decided to join her, I consented to join as well, not be left out of an adventure. Charles set up all of the logistics, and the next day we were preparing to jump out of a plane 10,000 feet in the air! The morning of our jump was a blur of fear and excitement for myself. The more I talked about it, however, the more comfortable I became and all my fears shifted to sheer excitement. Before I knew it, I was harnessed up and ready to board my plane. The plane was tiny, with chairs only for the pilots with 6 passengers seated on the floor behind the pilot. The ascent took 30 minutes, during which we were able to view the beautiful beach of Namibia and the Namib desert. I was also strapped to an experienced jumper, who would control parachute. After reaching 10,000 feet, we were brought to the edge of the door and before I knew it, I was in complete free fall. These 30 seconds contain the most exciting experience of my life, hands down. Once the chute was pulled, the descent down was nothing short of surreal. The entire jump was over in just over 5 minutes. Words cannot possibly describe the experience, so I will leave it to the photo of myself to describe my emotions.
           The rest of our time in Swakopmund was filled with time spent hanging out on the beach, and finding more unique restaurants. One of these restaurants was built at the end of a dock that extended into the ocean. On the night we went, it was a particularly windy and rough night for the water. This made the view and experience of eating on the ocean even more special.
The view from our house.
           The next day, we cleaned our house, and struggled with the landlady in getting our deposit back (a struggle in which we have been unsuccessful thus far). But no matter, despite spending nearly an entire day on this frustrating business, we eventually caught a combi back to Windhoek. On the ride, I had a conversation with a friendly man, who eventually found us a ride back to the hostel where we would be staying. We stayed in Windhoek for two more nights, spending the next day exploring the city further. Finally, our adventures in Namibia had come to an end, and it was time to make the long journey back to Gaborone. On Monday morning, we took the 6:00am bus out of Windhoek. The bus was exactly the same as the one we took on the journey into Windhoek, and equally as miserable. After 14 hours on the hot, cramped bus, we finally arrived back in Gaborone. Still not quite ready for vacation to be over, it was time to prepare for the second half of our semester at UB.

            Okay, this post became more detailed than I thought was in me, so I will end it here. Some of the finer points may not be in the exact order in which they happened, so if any of my friends disagree with the order of events, I apologize. I will also soon try to post about my recent trip to Durban, South Africa. I am planning a trip to Cape Town, South Africa as well, so stay posted for more updates. More about health care is soon to come as well. Classes are officially over now, and tests begin on Tuesday. It doesn’t seem possible that the semester is nearly over!