Bush League

Last night we went to the circus. We haven't been able to drive anywhere without passing the tents for the past week, so I decided I had to see it. Wow. Apparently there is no handbook of international circus standards.

To start, as soon as we pushed our way into the dusty tent, there was no hope of leaving for water, food, bathroom, or, as Ryan Davis pointed out, fire escape. We paid 90 pula ($12) for "Ringside Seats," which meant we were placed 3 feet from the caged tiger entrance. Mostly, it meant we had the best view of the carnies smoking cigarettes on the sidelines. It also gave us a nice view of the extreme terror on the faces of Rita the tiger trainer and her backup man with pockets of meat as the 6 enormous Bengal Tigers seemed to do disobey them in just about every way possible. As hell broke loose, her fake plastered smile got wider and wider. This happened again with the poodles, the horses, the ponies, and even the acrobats.

There were only six human performers who kept reappearing in different sparkly garb with different stage names such as Magic Rashid, Mongolian Jugglers, and Feline Frenzy. Then, during the intermission, the talent all put on hair nets and served cotton candy, popcorn, and light-up swords to the crowd.

Overall, it was a good time, no one was eaten alive, and we had some fun with cotton candy...

Happy Birthday Sarah!

Sarah's birthday party was a great success! Lots of friends, balloons, and even a 4-month-old (apparently no one gets left out of the fun, including our maid's two very small children).

The Ryans, Tessa, and I sneakily made a cake earlier in the day. Tessa, using her veterinarian vision, made a perfectly-striped zebra cake! Then we ruined everything with the frosting, so it was promptly covered it in neon sprinkles in what became a Lisa Frank nightmare. But it still tasted good!
Pictured here from right to left: Trynos, our mechanic, his friend Bruce, Erin with Tando, Sarah, and Cousin Ryan. Trynos was surprised and impressed that the Dingo and I had made it all the way to Ramotswa and back. I don't know which of us he doubted more...

Hunt for Pneumonia

I survived my first 40 km drive, dodging goats and potholes, to Ramotswa, on a hunt for more pneumonia patients at Bamalete Lutheran Hospital. Not going to lie, I was sweating bullets in the roundabouts and just about every time I passed a car on the highway in my too-close-for-comfort right-sided driver seat.

I was paired up with Dr. M, a jolly generalist from Zimbabwe. When I say generalist, I mean that I followed him back and forth between the outpatient clinic, maternity ward, and operating theater. Old school docs here have all been trained to practice medicine anywhere at anytime, and they find the idea of an orthopedist or a dermatologist ridiculous.

My goal was to feel the place out in terms of its pneumonia burden. I saw a vacuum birth, an abdominal mass, a few broken bones, a LOT of hypertension, one case of the hiccups, and no pneumonia. Looks like I will not be returning to Bamalete...

The highlight of the day was definitely Dr. M, who grew up with the African health system, but still finds humor in its ridiculousness. He told many stories, such as a patient who drove 200 miles to get his blood sugar checked, and when he arrived, he was carrying a glucometer.
"Why didn't you check it yourself?" Dr. M asked.
"Because this is the clinic where I received the diagnosis," answered the patient.
"I was diagnosed with diabetes in Scotland," answered Dr. M, "but that doesn't mean I need to go back there."

A woman today was worried about gaining weight while pregnant: "I've gained some recently," she said.
"No, no. You were much bigger the last time I saw you," replied Dr. M.

On the drive back, I missed my turn approximately 12 times, but I made it. Sarah's birthday is tomorrow! Stay tuned for lots of pictures from her party!

What ate your baby?

Our new Mitsubishi Dingo! Spacious like a minivan, yet small enough for us not to be soccer moms. It's not either of the two we were considering earlier, because when Trynos, our 6'6" mechanic, pulled up in the Dingo, we just knew. When we drove to the UPenn-Botswana office after picking it up today, the office staff flooded outside to see it. Most actually climbed inside and shut the door to get a good feel. Proud car-owner moment.

The rest of the day was a mix of excitement and terror, as we took our first solo mission driving on the left side of the road. When I test drove a different car last weekend, I discovered what a neurological hemineglect syndrome must be like when I ran the left side of the car (along with Trynos who had the window open) into a thorn bush. It's weird to worry about so much car on the left! Anyway, the neglect syndrome was in full force today as Sarah and I both gripped the left-sided passenger seat as the other occasionally straddled the the white lines.

The Dingo's most impressive feature is its ability to fold all four seats into beds! Camping here we come! No tent necessary!!
Here's a glimpse of the car-buying process...

Poll: Which Car No One Has Ever Heard Of Should I Buy?

Cheaper..................................................Nuff Said.......................................

Reflections on Setswana

Walk around Gabs for 5 minutes, and you will hear an echo of, "Ee mma,"which means "Yes, mam." However, it seems to me that people also just say it to fill space. Instead of sighing, they say, "Ee mma".

I have been riding the combi (public transport van) to the gym most days, and somehow I always end up in the furthest back corner, wedged in between a large "mma" and a fiendishly texting teenager. Getting the driver to stop has proved challenging. I started out yelling, "GymActive," but I felt like a tool. Then I switched to "GymActive rra (sir)," but I can't roll my "r"s, so that was also embarassing. Finally, I inquired about the word for "stop," and I learned that it's "ema," which sounds a whole lot like, "ee mma". I tried this out yesterday, screaming "ema!", and after 5 seconds without a reaction, one of the passengers turned around and realized I was trying to communicate something. He muttered something else, the combi stopped, and I exited past rows of chuckling passengers. Maybe I'll get it next time...

All Hospitals Are Not Created Equal

The past couple days have been a whirlwind introduction to health care in Botswana. The Botswana Ministry of Health hasn't approved my pneumonia project yet, so in the next couple weeks, I'm trying to get as familiar with the hospital and staff as I can, so that as soon as I hear from the Ministry, I can start enrolling patients immediately.

Here's a little background on what I'm hoping to do this year if you're interested: My project will involve scoring patients who come into the Emergency Department with pneumonia. I'm hoping that a simple scoring system that works in the US in HIV-negative populations, can be used here in HIV+ patients to help triage those who need to be admitted to the hospital and those who can safely be sent home.

My first task was to spend a day in the ER (here called A&E for Accident and Emergency) to get a sense of the patient flow...or lack thereof. The head of A&E is actually an American doctor who's been working here for 3 years and has made huge strides in the department, including introducing seemingly obvious things like a triage board. I joined him yesterday afternoon and proceeded to sprint around the A&E after him until utter exhaustion. The first patient we saw was a 3 yr old girl who had sudden right-sided paralysis and inability to speak. She was in room C1 (corridor 1), meaning she was on one of the three stretchers in the main hallway amid all the traffic. She was lying on her side in a tense, crooked position on the stretcher at 4pm when I arrived, and she was in the same position in the same spot when I left at 10pm. I could be incredibly frustrated by this, and I am, but frankly, after also spending time on the inpatient wards, I do not think a speedy admission would have improved her care very much.

Next I wanted to get the hang of enrolling patients in research studies, so this morning I joined another research team's study nurses on an outreach mission to enroll patients. They enroll newly diagnosed HIV+ patients and take blood samples at different time points after starting HAART (Highly Active Anti-Retroviral Therapy). We went to a few local clinics toting a small cooler for the blood samples, and I basically stood quietly for many hours while they filled out surveys with patients in Setswana. I learned three things: 1) You cannot make any generalizations about who gets HIV here. It's everyone. 2) There is no such thing as patient privacy. The nurses took disease histories, sexual histories, everything, in a room with all the other patients listening in. 3) I need to learn Setswana.

I had barely gotten out of the car at the UPenn office when the sassy study nurses from my team snatched me up into their car to go on another outreach mission. I thought we were going down the road...Nope! We drove 1.5 hrs through miles and miles of flat farmland, dodging goats, until we got to a primary hospital that starts with a "p", but I am so bad at remembering these crazy long names, so I will get back to you. Hospitals here are organized into primary, district, and referral hospitals. Princess Marina, where I will be enrolling, is a referral hospital, which basically means that it has some modern medical equipment (like automatic blood pressure cuffs) and "specialists" (like pediatricians).

Anyway, at the primary hospital today, Susan and Mama Molapisi (in the pic walking into the hospital) were leading a focus group of nurses to get feedback on a newly drafted guideline for Botswana for the management of acute coronary syndromes (heart attacks). I was so proud to be joining this team after seeing how fierce and brilliant these ladies were at mobilizing this focus group. Susan gave a beautiful and inspiring speech about the nurses standing up for themselves and demanding a higher standard of care. It was pretty shocking when the first nurse finally spoke up and said, "I don't think this guideline will work, because it all depends on having an ECG machine, and we have never had one." It later came out that they also do not have anticoagulation, or a lab. And yet it still called itself a hospital. For the non-medical people, that basically means if someone comes to that hospital having a heart attack, all they get is an aspirin. I can totally sense my parents' fear right now. Yep, pretty scary.

Anyway, that's just the tip of the iceberg. It's going to be a fascinating year. Right now I am just ready for a weekend.

Contact info: Have I Mentioned Lately How Much You Mean to Me?

(Letters)

Botswana-UPenn Partnership
PO Box AC 157 ACH
Gaborone
Botswana

(Courier: Fedex/DHL - Much more reliable for anything other than letters)
Botswana-Upenn Partnership
C/O Nikki Jones
214 Independence Avenue
Gaborone
Botswana

Africa for Beginners

1.Gaborone has two-story shopping centers with electronics stores with multiple rows of high-def speakers.
2. I bought soymilk at the grocery store (granted, it is called NutriBev, and it tastes like Maalox, but it's dairy-free).
3. I found a sports shop with speedos and swam in the 25 meter pool at my new gym.
4. True Blood is currently downloading on my computer (1 sec of video/minute...but it's downloading).
5. I got a text today from a Motswana we met this weekend who has a fake British accent.
6. We always have power.

I Think I'll Make It

Unanimous vote that Sanitas garden store and restaurant will be a popular retreat. The tables were shaded by a giant fruit tree, and the breeze was lovely until the onslaught of rock-hard bee bees from the tree that ricocheted off lemonade and into eyes and casseroles.

Here is your first glimpse of Fogarty Fellow Ryan W., who has every medical-ish degree known to man (PharmD, MD, PhD). More importantly, he has a 4-wheel drive cruiser and a pool. Fogarty-Fullbright Fellow Ryan Davis is taking the picture. From hereon, they will simply be referred to as "The Ryans". Sarah is wearing blue, and Erin, a 4th yr med student from UPenn, is in red.Because everyone needs more than 2 Ryans, we met Ryan #3 yesterday at his house party. He runs the UPenn dermatology telecommunication project and has been living in Bots for 2 years. After losing miserably at Cranium South Africa (half of the answers required tongue clicks), I nearly got into a fist fight with a Batswana (Botswana native) who graduated from Amherst. Small world!

Wait for it...our competitors in Cranium also included Miss Botswana 2010, who was runner up at Miss World 2010. I just spent ten minutes confirming this on YouTube. Crazy.

Touchdown in the dust bowl

Five days in Gaborone, Botswana under my belt! I will be living here for 9 months doing clnical research with UPenn. My project involves validating the CRB-65 pneumonia severity score in a predominantly HIV-positive population (if that means anything to you).

I picked this stunning brown color scheme because I think it represents the landscape quite nicely. As we approached Gabs in our miniscule propeller plane, after 16 hrs on a larger plane with a BROKEN ENTERTAINMENT SYSTEM (see sad face picture attached), the flat orange dust with occasional pockets of brush called out to us as "home". I should clarify that "we" refers to me and Sarah, my partner in crime in my UPenn/Botswana adventure. After 2 months living together in Philly before arriving, we are decidedly co-dependent life partners for the year. In fact, we tried to get a couples discount at the gym the other day (after touring its gorgeous ourdoor 25 meter lap pool with our local real estate agent who repeatedly called us the "n" word, naturally, because we're American), but they wanted a marriage license.

We did, however, find an apartment! I'm referring to it as the "posh palace", because it is a fully-furnished mecca of appliances and cable television. The 20ft cement wall with another 10 ft of electric wires on top enclosing our landscaped patio should keep us incredibly safe, though I do not think that's what prisoners usually think when living in similar circumstances. Anyway, it's walking distance to the hospital and to Riverwalk, our mega mall, so I'm pretty satisfied.

That brings me to our next beast...buying a car. I have to admit that I am less worried about enrolling pneumonia patients without speaking a word of Setswana than I am about learning to drive on the left side of the road with a stick shift on the left. We are headed to "Motor City" this weekend, which is basically a giant alley of Japanese cars that failed emissions testing. After riding in a friend's car last night that is now missing both mirrors due to "charging goats", I am thinking this will be an interesting investment. Sarah learned the rules of the road the other day: If you hit a cow on a major highway, you have to find its owner, and they pay for the car damage. On the other hand, if you hit a cow on a smaller farm road, you have to find the owner, and pay for the cow.

More to come! Heading to lunch now at Sanitas, the city's premiere garden tea room.