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. 

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 31^st, 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. 

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!

Swakopmund

Travelers

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)

Cemetery

Tombstone

The driveway

The road outside the hosue

Experiences and Reflections from Serowe Healthcare

       
  There were eight students who traveled to Serowe to learn about the healthcare of Botswana in a village setting. We split up into 3 groups, each group assigned to a certain clinic in the village. I and two other students were assigned to Serowe clinic, which was a mere ten-minute walk from the neighborhood in which we were staying. We arrived at the clinic early Monday morning and were introduced to the head nurse. The nurse showed us around the clinic and then told us to allocate ourselves to different areas of the clinic. The three of us began by working in the child welfare clinic, which is run very similarly to the one in Gaborone. Mothers bring in their children up to five years of age to be weighed and to measure their heights. This is done each month and the results are recorded on a graph in the patient chart. The height and weight data is compared with each other; if a child is underweight, a third test is done to clarify the results. They use a tape-measure armband to measure the circumference of the upper arm. If the distance does not meet the marked ‘green-zone’ then the child is considered to be malnourished. In this situation the mother will be counseled on proper care of her child, and appropriate amounts of food will be distributed to the family.

Although English is the official language of the Botswana, it is not the first language of any of the locals. We faced the inevitable barrier in trying to inquire about the effectiveness of these tests. In the child welfare clinic height and weight are recorded in different charts and did not seem to be correlated. In addition, the confirmatory armband test did not have any dependency on the age of the child. From one month to five years the same band is used to confirm malnutrition, which seemed counterintuitive to us. When we asked the nurse about its effectiveness across this wide age range, she went on to explain to us how they check for malnutrition, a process we mostly understood at this point. Later in the week, we put the question to another doctor who explained to us that the height and weight are combined in diagnosing malnutrition in a child. The uncertainty of the armband, however, was an issue that was never resolved for us.

Mondays and Fridays are ARV (anti-retroviral) days in Serowe Clinic. On these days, patients come in to begin or continue ARV treatment. Patients also come for general consultation as well. There were two doctors seeing patients in the consultation rooms. In the afternoon I shadowed a young doctor named Paul. On this afternoon, Paul saw various cases including: HIV, cysts, various skin irritations, and possible tuberculosis. TB is an illness that has become a major issue in Botswana, and across most of the developing world, especially where HIV is prevalent. I asked the doctor if patients suspected of TB are ever asked to wear masks to protect the workers. He said they do not do this unless this patient has multi-drug resistant (MDR) TB. He explained that nearly everyone who works in health in Botswana would test positive for TB. Apprehension for my own health aside, this did not seem like the best public health policy. After all, MDR-TB is born out of non-MDR-TB and control of the latter should lead to control of the former; or at least reduce its proliferation. In addition, if health workers are not properly protecting themselves from TB, they also put at risk patients who are negative for TB; a risk multiplied in a nation that carries the second highest HIV prevalence in the world.

Working in the clinics has been an indispensably informative experience in learning about healthcare delivery in Botswana, however there has been a nagging tendency to get the idea that HIV is not as a big of a problem as it has been made out to be. In the clinics, patients have rarely reached a stage of the disease that is devastating, and most seem healthy. On our last day in Serowe, we were taken to the Sekgoma Hospital, to have our doubts stripped away. It was Friday, ARV day, and we walked in to an excessively bustling clinic. We pushed our way through the crowd of people surrounding the two consultation rooms, and made our way in to talk to one of the doctors. There was a new, more senior doctor in today to see patients. He told us that with the amount of people needing to be seen, he would not have time to talk to us about the patients, and didn’t feel that our experience with him on this day would be worthwhile. Instead, he called the hospital and arranged for us to shadow some doctors at Sekgoma. We caught a cab outside the clinic, and within minutes found ourselves in the accidents and emergencies ward, searching for the doctor. Upon fulfilling our search, the doctor showed us to the patient he was currently seeing: a man with Stevens Johnson syndrome, which is an allergic reaction to the sulfur-based ARV medication. This is a life-threatening skin condition in which cell death causes the dermis to separate from the epidermis. When we first saw the patient, I thought that he had been victim to a serious burn. However, the burns were found in patches all over his body. The doctor then explained to us the cause of this patient’s pain. After this, the doctor decided to take us to the general ward of the hospital. As we walked through the halls of this large hospital, the most noticeable feature of the building was its desolation. The halls were empty. However, when we reached our destination, we found a busy ward. We were introduced to a doctor from Cuba, who was seeing patients of all sorts of ailments. There were two cases, however, that have been fixed in my memory. The first was an HIV-positive patient suffering from cancer of the throat. We were allowed to view this for ourselves, and we saw a large tumor at base of the tongue of a young woman. The woman had come in due to complications, but was about to be released from the hospital. She was waiting on biopsy results to return from Gaborone, and the doctors could not operate until their arrival. We were informed that biopsy results could take up to 2 months to make it back to Sekgoma hospital in Serowe. The second patient we saw was a young woman in her mid-20s suffering from AIDS related wasting syndrome. The woman had failed to properly take her ARV medication, and the disease was now consuming her body. At home, she lived alone, and lacked any familial support in her burden. Now she was laying in the hospital bed at Sekgoma, staring blankly into the wall, as the doctor examined her and moved onto the next patient. This was our first true exposure to a patient whose life has been devastated by HIV, and she is not alone. Later in the pediatrics ward, we were shown a baby who had contracted HIV at birth, and now was suffering from TB and malnutrition. Botswana has implemented a very successful program called Preventing Mother-to-Child Transmission of HIV (PMTCT), which has greatly reduced the number of babies contracting HIV at birth. Unfortunately, however, not every mother follows the program, and the program itself is not 100% successful. On rare occasions, babies such as this one are unfortunate to contract the disease at birth. While the reduction of this has been a success for Public Health in Botswana, hopefully soon it will become a total victory.

Our experience at Sekgoma hospital has been the most invaluable one of our stay in Botswana thus far. Here, we were exposed to the true impact of HIV on the lives of people of Botswana. We also were able to talk to many different doctors about practicing in Botswana, and further explore the dynamics of the healthcare system and the relationship of doctor and patient in this country.

                                             
                                              (Note: all photos in this post taken by Dina Fico)

Weighing babies

The armband used to check for malnutrition 

Karata -- The patient's chart

The pharmacy

Reflections

In the clinic in Gaborone most patients speak English well, however many prefer to communicate in Setswana. This is because most patients are most comfortable expressing themselves in Setswana and are able to understand instructions from caregivers more accurately. Still, English is a viable option when caregivers are unable to speak Setswana, as is the case with most doctors in Botswana. However, in the Serowe clinic, very few patients spoke English. This is a major problem for the country, as most of the doctor positions are filled by expatriates. The main reason for this problem is the lack of a proper medical school in the country. As I mentioned before, the University of Botswana has recently created a medical school, however, it has yet to gain accreditation or respect in the medical field. Until the School of Medicine establishes itself, the government of Botswana will continue to send medical students abroad to receive education. Because of this, the vast majority of students fail to return to Botswana to practice.

           One of the most interesting things about shadowing healthcare workers on the ground is to hear the varying opinions about the system and its future. So much about the jobs of these workers is dependent on policies put in place by the government. This is not unique to Botswana either. I remember shadowing various doctors after the passage of the new Healthcare law in the U.S. last year. Opinions I received ranged anywhere from passionate enthusiasm to gloomy uncertainty about the future. Perhaps it is a testament to the nature of healthcare work that providers are able to continue their jobs effectively even in the face of so much uncertainty and confusion. It is well known that hospitals anywhere in the world are a hub for human suffering, and the attitudes of those who work in these places are undoubtedly affected and shaped by this fact. Then again, perhaps I am merely romanticizing the profession to which I plan to dedicate my life. Either way, these professionals all have serious opinions about the systems in which they work. In Serowe, I heard doctors and nurses cursing the system under which they work; complaining about lack of supplies and personnel. ‘Botswana is a disaster!’ One nurse said this to me speaking about the healthcare system of Botswana. On this particular day, no doctor had shown up to the clinic, so this nurse was put in charge of consultations for the day. This means she performs all the duties of a doctor, including prescription of drugs, with the exception of interpreting lab results. This particular nurse was very young and was only 6 months out of school. I asked if this was a common occurrence, and she explained that on her first day out of school, she was asked to perform consultations; answer: very common. Another doctor explained his discontent with the system after being unable to find examination gloves in the consultation room. In addition, the water supply to the clinic had been mysteriously halted, a problem, which was not resolved for several days. He told me that a major problem in Botswana is the allocation of funds within the system. ‘Those in the Ministry of Health who are creating policies are not doctors, they are politicians.’ This doctor was a Motswana, and although his consultations were mostly in Setswana, it was clear to me that he was able to relate to his patients much more effectively than other doctors I have shadowed. Unfortunately, his dismay with the system was enough for him to desire to practice in a different country. It was clear that these practitioners had serious quarrels with the system of care and were not simply venting frustration.

            Still, others we talked to were very confident in the system implemented in Botswana. There is no doubt that the delivery of free ARVs to citizens of Botswana has been extremely effective. When ARV treatment was initially discovered, treatment was virtually unavailable for the general population of Africa that had been the hardest hit in the world. This was due, in part, to monopolization by pharmaceutical companies, preventing affordable treatment to areas of greatest need. Today, the price of ARV treatment has been massively reduced, and the government of Botswana has managed to provide free treatment to every citizen in the country. This success has been an inspiration of hope to sub-Saharan Africa in the fight against the HIV pandemic. Unfortunately, many countries still do not have access to the life saving treatment that can dramatically extend and improve the quality of life for people suffering from HIV infection. Botswana, however, offers treatment to all citizens of its country, allowing those living with HIV to have a much-improved quality of life when compared to neighboring countries, such as Zimbabwe or Zambia. Dr. James Orbinski, former president of Médecins Sans Frontières (Doctors Without Borders), said in his 2008 book, “AIDS is a fully treatable disease – as treatable as diabetes. Yet today, worldwide, 30 million people have died of the disease, 33 million live with HIV infection, and upwards of 100 million may be infected by 2020.” There is no doubt that Botswana is at the forefront of the fight to make ARV treatment available to all areas afflicted by HIV/AIDS.

            When comparing healthcare in Serowe to that in Gaborone, the biggest noticeable difference is the lack of proper personnel in the clinics. The Gaborone clinic in which we have been involved with is actually very well staffed, and the organization of each ward runs smoothly together. Apart from this, many of the same problems with lack of supplies and barriers in communication are still felt.

            Hopefully you now have some idea of the various things I have been doing relating to healthcare, and of my experiences in Serowe. Many of the thoughts provided in these reflections are applicable both to Serowe and Gaborone. As the semester moves along, I am beginning to gain an understanding of the dynamics of the diseases around which the system of healthcare in this country are based. 

Children after a public health discussion on Safe Male Circumcision

Vaccinations at a school

The public health group

Village Homestay in Serowe

          Recently, the CIEE Public Health students spent the week in the nearby village of Serowe, which is about 300km (180mi) North of Gaborone. We took the public bus from Gaborone to get there, which took around 4 hours. We arrived in the evening, and were greeted by the families, which would be housing our group for the entire week. The host-parents were preparing a welcome meal for our group at the host-home of one of the CIEE girls. At this dinner, I met Sebeo, Zwabo, and Tjango (prounced Chango). Sebeo is a 96-year old grandfather to Zwabo, who is 30 (ish?); and Tjango is Zwabo’s 4 year old son. After a short period of visiting, the food was ready, and we ate our fill of traditional Setswana food, very similar to what has been described previously. It consisted of porridge, papa, chicken, beef, Mopani worms, and a couple other traditional dishes (the names of which have escaped me). After dinner, we were welcomed with a ceremony put on by the families. During this ceremony, the local pastor said a prayer for our well-being, several of the Moms, as well as my grandfather stood up and welcomed us in different ways. Everything that was said was spoken in Setswana with another person translating to English or vice versa. Between each speaker they would sing a song, the only word of which I could make out was ‘Modimo,’ which in Setswana means ‘God.’ Finally, we all split up to go home and be introduced to the rest of our families.

The house where I was staying is only a short walk from where our dinner took place, so Zwabo guided me through the dark dirt roads of the village to our destination. At the house, I met Morwadi, Korraba, and Thaboga. Morwadi is the wife to Zwabo, Korraba is their 6 year old daughter, and Thaboga is their two month old newborn. I also met Oduetse (OD), a cousin to Zwabo who is staying in their home. I was also given the Kalanga name ‘Zwango,’ which means ‘mine.’ Kalanga is the tribe, which Zwabo and his family come from. It is one of the biggest tribes in Botswana. At first, I wasn’t exactly sure of my place in the family. Was I the son of Sebeo, making me the uncle to Zwabo? Or the son of Zwabo, making me the great-grandson to Sebeo? Everyone else in the group would talk about their host-Mom and brothers and sisters, while I was left somewhat confused as to what to call my family. Fortunately, this gave me all the more reason to learn their names quickly. Even though Zwabo assumed more of a fatherly position, in showing me around the house and village, Morwadi eventually called me her brother giving me certainty of my place in the family.

On our first morning together, OD showed me how to do some of the daily chores, including wood splitting, chopping down tree branches, cooking porridge, and hand-washing clothes. That night, everyone gathered around the TV to watch Ghana and Mali play in the consolation match of the Africa Cup of Nations. Mali upset Ghana in a 2-0 victory. The next night, Zambia would win the Cup on penalty kicks in a 0-0 game. Unfortunately, I fell asleep during half-time of this game, which is basically the Super Bowl of Africa, and as far as the quality of game goes, it was as good if not better than our own Super Bowl. Side note: I stayed up until 7 in the morning to watch the American Super Bowl, which didn’t start until 2am in Botswana…

Throughout the week, OD would continue to show me various chores around the house, and Zwabo showed me some interesting things in the village. On one of the days, he wanted to show me how a destitute Motswana lives. He took me to see his friend who has several kids, and is sustaining his family by selling Chubuku beer. This is a local beer that is very popular. Unfortunately, however the government has now issued a law saying that it will no longer be legal to sell alcohol from a residential home. People who sell this beer, will now have to rent a business plot to continue their sales. For the person we talked to, this was simply impossible. We talked for a long time about how he had ended up in this business and what his future looks like. He is very concerned, because when the law takes effect, he will no longer be able to sustain his business. He is living day-to-day trying to figure out what to do next. We also went into the main mall in town, where we saw a bustling local market. This one was much more authentic to Africa as compared to what we have seen in Gaborone. Small tents were set up on either side of a long alley, between the larger stores. The merchants were selling everything from dried Mopani worms, to various nuts, fruits, and vegetables. One of the girls I was with, who for some bizarre reason actually enjoys Mopani worms tried these dried worms and was not satisfied. Aside from that, we did not buy anything else as we have been warned against consuming food sold from street vendors especially when it is uncooked.

One night, one of the host-mothers took us to her brother’s local farm, which took about an hour to drive to on very rough dirt roads. When we got there, her brother showed us around his farm, where he has cattle, goats, sheep, and chickens. When we arrived, they had just milked one of the cows, and we were able to taste some fresh milk, straight from the utter! As the sun was setting, we had the privilege of experiencing one of the most colorful sunsets I have ever seen. I watched the sky as the clouds shifted from blue to yellow to pink to orange and faded back to blue as the day turned into night. I will post a picture at the end of this post, because no words could do it justice. The picture is not my own, but taken by another student.

The homestay in Serowe was without doubt one of the highlights of my experience so far. In the next post I will talk about our experiences in the health field of the village, however learning about the culture through my family, as well as that of other students, and simply talking to local people gave me a multitude of knowledge in itself. There is no doubt in my mind that while the village of Serowe is one of the largest in the country, and would be more accurately described as a town, it seemed to be more authentically ‘African’ than Gaborone. It was easy to see here that much of the lifestyle remains unaffected by the modernization of the country.

I am currently running behind on my posts, with school and travels it has been hard to find the necessary time to put together the right words to help you to share in my experience. Next, I will be talking about the healthcare in Serowe, and perhaps dig a little deeper into some of the problems and advantages of the current system in Botswana. Last week I traveled to the country of Namibia for our vacation, which was an amazing experience. I will do a post about that when I have time as well. I also hope to post more pictures, however uploading them to blogger takes a lot of time, for more pictures you can see my facebook profile here:

http://www.facebook.com/profile.php?id=1315470053&ref=tn_tnmn

Until our next digital rendezvous..

Take care!

                                     (photo by Shilin Zhou)

TCM