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!


Thursday, April 12, 2012

Memorial Service in Lobatse

            Two weeks ago a friend of mine, named Thumesang invited me to his home in Lobatse, to attend the unveiling of three tombstones of family members who had passed away between 1999 and 2003. When he initially asked me, I thought the family member was some distant relative, however the night before we left, he told me the memorial was for his grandfather, who had basically raised him.
After an extremely busy Friday, two other international students and I headed to the station to catch the last bus of the night to the village of Lobatse. After an interesting conversation on the bus, Thumesang greeted us at the bus stop, where he introduced us to two of his cousins. Then he drove us to his home, and we were greeted by a multitude of people. We walked through the gates and saw many people sitting on chairs on the patio. We then walked into the small but bustling house and squeezed through various rooms until we came to the room of his grandmother. She was lying on the bed, and we briefly introduced ourselves. As we roamed the house, we were introduced to many cousins, aunts, uncles, brothers etc. His family was unlike any I have seen. Everyone was delighted to meet us and extremely kind. After touring the house, we went to the backyard where the food was being prepared. There were two separate areas set up for cooking meat. One was designated for the men and one for the women. In line, the women’s section came first, so we met more relatives and talked briefly, trying to learn more Setswana words and promising to help prepare food. We continued to the men’s section where meat was the sole food being prepared. The meat is cooked in giant cauldrons over an open fire with bones still attached. In addition, a separate cauldron is used to cook Serobe. This is basically the entire gastro-intestinal tract of the cow sliced up and salted, despite my hesitation it was actually very tasty. After continuing to meet people, we helped the ladies cut cabbage in preparation for coleslaw. After some time here, Thumesang brought me back to the men’s section. I helped slice up the Serobe using basically a large scissors. I took turns between several other men slicing the intestines and stomach into small pieces. At various intervals, I would see someone open the cauldron and stir it with a large stick. This is basically a staff with a Y shaped at the end to turn the meat. The meat is packed tightly in the cauldron, so the stirrer must dig the stick deep into the pot and turn over the many large portions of meat. After some time, a lady walked around with a large bucket and a pitcher of water for everyone to wash their hands. After this, a meal was served to everyone, made up of a large portion of pap (as usual), a slice of beef and serobe. As is the traditional custom, we all ate with our hands. Fortunately, the consistency of pap allows you to form it into a sort of spoon, which makes eating with your hands much easier, though I was still laughed at for using two hands.
Eventually the night led us into the kitchen where tea and biscuits were being served. My friends and I all sat around the table and talked to several ladies for some time. The hour was drawing towards midnight, and while I wasn’t ready for bed, I began to wonder if the house would ever wind down enough for people to sleep. My doubts were validated, during these events they really don’t sleep. “No time for sleep,” we were told. Many of the family members spend the entire night preparing for the morning ceremonies. Eventually, Thumesang drove us around the village in a van, and when we returned we passed out for a couple of hours in the van. Thumesang, who had not slept a wink, awoke us around 5:30am. Services were planned to begin at 6am. We arose in the dark and prepared for the day. We were served coffee and biscuits for breakfast, and the services began before we were ready. We were not the only ones unprepared however; the house and backyard were bustling with commotion the entire morning. Although nearly everyday in Botswana has been exceedingly hot, this morning in Lobatse was the opposite; too cold for even us Americans, all of who come from areas with bitter winters, to even be comfortable. In addition, the services were spoken nearly completely in Setswana, with the occasional English word slipping in. Several family members stood up to speak about the lives of the three people who were being commemorated today.
After all the speakers had their turn, people began to process to the cemetery. We caught a ride with a friendly man, who is married an aunt of Thumesang. As we drove through Lobatse in the light, we realized the beauty of the landscape. The town is set at the bottom of several major hills. These large hills surround the town, and parts of the town itself are built into smaller slopes. The cemetery is built at the base of one of the large hills. Most of the graves have an iron cage built above it with an awning structure on top. In addition, the weeds grow freely throughout most of the cemetery, making it hard to traverse. We began at the tombstone of the grandfather. Hymns were sung, prayers sent forth, and inspirational psalm verses read. After all had had their turn, the crowd processed around the tombstone to view the newly installed work. I would guess that around 100 people were present at the cemetery. After circling the stone, the line moved to the next tombstone to be unveiled, which was that of the daughter of the grandfather. During the prayers, a woman began crying as she was placing flowers on the grave. The life of this woman had been taken much too young. We followed the same procedure to the other side of the cemetery for the unveiling of the brother’s stone. Finally, after all the prayers had been said and songs were raised to ‘Modimo’ the people began to disperse and head back to the house for the feast. Since our ride was down the street from our exit of the cemetery, we had to walk along the road for some distance before getting into our pickup. As we were walking, nothing short of 10 different cars stopped to make sure we had a ride to the house – a simple, yet shining example of the kindness we were shown.
            Finally, we arrived back at the house, where tables were set up in the street, and chairs lined the sides of the road into the patio of the house. We assisted in serving ‘ginger beer’ which is a traditional juice. Eventually, we were able to serve ourselves food, a not so easy task in a line full of hungry hands thrusting their plates at the servers. We were able to finally push ourselves through and claim our food. We then sat down and feasted. Pap, cabbage, beets, squash, potatoes, and seswaa (basically ground beef, with small bits of bone that are ground in with the beef). Throughout our meal, various people stopped to introduce themselves and ask about our stay in Botswana. After our meal, we continued to socialize until finally the same kind man who drove us to the cemetery offered us a ride back to Gaborone, allowing us to avoid the bus. We accepted, and after many good-byes and ‘Go Siame’s’ (Setswana for good-bye) we were on our way back to the city. Our exposure to another traditional ceremony in Botswana had ended as quickly as it began.

                                           (Note: All pictures taken by Dina Fico)


The driveway

The road outside the hosue