Dr Livingstone, I presume?

Most people know of him as the quite man Scottish man who was the first non-African to see Victoria falls, trace the Zambezi river, see Lake Malawi, and traverse southern Africa from Atlantic to Indian ocean. But before he was mad (probably "sleeping sickness" and cerebral malaria), he started a hospital in Molepolole, which is where I am now working. Apparently, even in the 1850s, he realized the excess infant mortality caused by home deliveries and started a system of obstetrical care that lasts to this day in the country.

Scottish Livingstone Hospital is now a much different place. It was a series of low buildings, now decrepit, until 6 years ago, when this literal palace was constructed for the hospital. It must be several blocks long and is a series of criss-crossing diamonds with inside courtyards with a grand entrance and internal enclosed atrium with natural light. Kate (my clinical mentor from Harvard) reassured me that I would feel strange walking in to "help out" here, but that fear would all go away when we entered the wards. This huge complex is really only about a 280 bed facility, and most beds are in "cubicles" of 6 beds, so the actual in use space is not such a high proportion.

With a usual census of about 200-260, there are 16 medical officers, one chief medical officer, one physician (meaning a specialist in adult medicine- he did an internal medicine residency) and one surgeon. The other medical officers are sort of like perpetual transitional interns. It must be a ridiculously hard job. They spend 3 months at a time on each ward: male and female medical, pediatric, obs-gynae, male and female surgical, TB and psych (same person staffs both) and then general outpatient clinic and Accidents &Emergency. There is one MO on call over night. This means they see all comers to A&E (usually 20 or so) and admit to themselves whomever is ill, do whatever surgeries are emergent-limited to "Ceasars" and appendectomies, rarely urgent colectomy or laparotomy (but they probably call in the surgeon for the last 2), and then take care of whatever else happens in the hospital....like pronouncing people dead, since most true emergencies often are not able to be managed. I can't imagine doing this work 1/16 nights and then the regular job 5 days a week. At the hospital, we are able to send most basic lab tests, do x-rays and ultrasounds, and send blood to Gabarone for HIV viral loads. Patients needing CT scans or cardiac ultrasounds or just needing a specialist of any kind need to go to Gabs to PMH. We also refer quite a few number of people with heart valve conditions etc to South Africa for heart surgery.

I spent my 1st 2 days at Princess Marina in Gabs and then have spent a few days each on Female Medical wards, IDCC-Infectious Diseases Clinic aka HIV clinic, and today on the TB ward. It is a very interesting position to be in, in that I am a specialist here (training in Internal Med vs "everything") and we are trying to do teaching on rounds the way an attending or senior resident might do at home, as well as help try to improve the processes, but also let Bots be Bots. My role is quite difficult because I am trying to capacity build by sort of acting as a consultant on rounds, trying to learn for myself, and also just make sure that our extra emphasis on learning doesn't prevent us from rounding on the 37 patients and drawing all the blood etc for the day.

There is an amazing diversity of cases, with so many people presenting with severe complications of HIV and TB. And then there are a lot of other things, but most people are in the hospital for one of those two unless they are there for diabetes or hypertension. And most patients are there for weeks if not longer.

TB and HIV are both huge problems here. The official prevalence of HIV in the country is 24%, but reaches as high as 50% in the pregnant women being screened in the higher prevalence areas in the mining areas and on the border with Zim. 50%!!! granted, all pregnant women have had sex, so they are at higher risk than others, but it is unbelievable. And it is thought that between 60-80% of HIV+ people harbor tuberculosis, so that in any given year, they have up to a 10% risk of reactivating the disease and becoming sick with TB. Every 1 in 4 people I see all day on the street is infected with HIV and at least 70-80% of the inpatients I see are as well.

Taking off for the weekend now.....probably back on the TB ward on monday. Giving a lecture on EKGs to the MOs at the hospital next week....they just got 6 EKG machines for the 1st time ever and so we're trying to help people put them into practice. Funny thing is though, that they have metal cups with a suction ball that is applied with ultrasound gel as opposed the the sticker electrodes used at home. Apparently, this is how they were done in 1970s in the US, though these are brand new machines!

Madikwe

So, for years now, I've been poo-pooing the safari experience thinking that the only valid way to really live in a new country is to travel and experience things as the locals do. And for those who know the way I travel, I like to bump around on public buses and eat at holes-in-the-wall and stay in rustic accommodations. I thought that working in a resource poor setting and tromping around the savanna in a range rover were mutually exclusive.

Boy was I wrong.

Oh, and thank goodness for the University of Pennsylvania.

Penn has a long-standing relationship with the main hospital in Gabs and there are always a mess of cool residents and med students and all of the deep secrets of where to travel to.

So, 8 of us including attendings and fellows, med students and residents (all Penn except me) got in a taxi to South Africa, which is 15 minutes away and then an hour of passport stamping, and then on the Madikwe game reserve, which touches the border with Bots, though is another good 30k in after crossing into ZA. This is a private reserve, meaning that you can't drive your car around inside, rather one has to stay at one of the many lodges and explore with one of their guides. This sounds kind of stringent, but after having done it, I realized I wouldn't have seen anything on our own, nor would we have been able to safely approach animals without a keen and ridiculously knowledgeable ranger.

Tau Game Lodge is an amazing place with main lodge and then guests stay in sort of traditional grass thatched huts like the rondavales, except equipped with decks looking out over the local watering hole and the best bathtub I have ever been in. Essentially, it's paradise. We showed up, they put a lemonade in your hand and then opened the doors to the viewing deck over the watering hole, where just by chance, zebra (pronounced zeh-brah by locals...who knew?), waterbok, springbok, impala, warthogs, kudu, and about 20 species of birds are all hanging out for a drink. Then your job is to birdwatch (choice of from top deck, pool deck, or your personal deck) and swim until 4:30, when we all pile into the range rovers with Morah, our awesome ranger, and drive around the bush until well after dark.

I'll let the pictures of the 4 game drives speak for themselves. Unfortunately, the camera was on the fritz, so I missed the last few lions and such. Essentially, we head out of camp and Morah tunes the radio to listen to the other rangers talk about the animals they are finding. Mostly just range animals that are pretty exotic to us, but you know, kind of run of the mill, like impala, oryx, kudu, waterbok (a large type of antelope) steirnbok (a large-house cat sized type of antelope) etc. But then someone radios a bull elephant at the dam, and we slam into reverse and rush down the single track to the holding spot where we wait our turn to approach the elephant. After which, he promptly stares us down and tries to decide how close he can get before we decide to let him have space (this is where trusting your ranger to read his body language is crucial...and also trusting that she's found an escape route for us if he's decided to get temperamental). The we cruise around a little more and WOW someone's spotted rhino....off running again. Before dark, we stop for some wine and snacks in the bush and then proceed to drive until it's well dark while swinging a search light into the hills for the nightlife. Seems crazy, but we find cervils, small spotted jenets, chameleons, and 3 species of owl, all while Morah is driving with one hand, holding her gun, and swinging a light across her hood into the hills on either side. Then back to the lodge, where we have dinner around a Boma, or traditional fire pit, and then play cards on the deck until midnight to the sound of a young male elephant trying to figure out how to be a teenager.

Next morning up at 6 for coffee and rusks and another drive until 9:30. This time it's 2 male lions, a crash of rhinos, buffalo, vildebest (wildebeast), eagles, guinea fowel, warthogs, and maybe a quick view of a leopard running through the bushes (maybe a cervil, but they might be even more rare and amazing-half leopard, half smaller cat). Back to the lodge for breakfast, a swim, some reading, lunch, reading, and then PM game drive. Repeat day 1 except for getting stuck in a herd of elephants (not recommended by the WHO or State department for health reasons). If you get in between a mom and her baby.....you get the point.

Oh yeah. and then we had a shit spitting contest. No lie. Apparently this is an international sport very popular in ZA, where one finds dried impala scat, puts it under your tongue, takes a swig of brandy, and then spits the scat as far as you can. Yes, I sucked on impala poo. Who wants a kiss?

Apart from this, an overall relaxing weekend. No more anti-safari from me.

Oh yes, and I do work in a hospital here. But I've only been at each of 2 hospitals for 2 days each and I just haven't finished absorbing things yet to get my head around a good post to write. Don't worry, there's one coming.

Here's a link to the photos....http://www.flickr.com/photos/deignacio/

Dumela Ma?

That's "How are you, Ma'am," which is about all I've learned to say in Setswana so far. Luckily pretty much everyone also speaks English.

I arrived in Gabarone (the capitol) Friday and am getting settled nicely into my rented room not far from the center of town and the main hospital here.

This is the start of a 5 week rotation via the Harvard Botswana Partnership at the Scottish Livingtone Hospital (as in Dr. Livingstone I presume. seriously) in Molepolole, about an hour from here. Tomorrow I start the work of clearing my phsyician's licensure so that I can officially practice here. The general plan is to then start working at SLH in a combination of sort of a "clinician educator" role working with the MOs (Medical Officers- the housestaff, except it's more of a 1year or more job than an academic learning position) which means that I'll be the "internal medicine specialist" doing teaching and helping out on rounds and also spending some time in the outpatient RVD (RetroViral Disease is code for HIV) clinics. BHP is working on some fabulous research here as well, which I won't be actually joining, but hope to at least scope out for future ventures. Work here ranges from being a large clinical testing site for the candidate HIV vaccine to various studies on optimal treatment of tuberculosis and HIV co-infection, timing of starting HIV treatment etc.

So far, I don't have much of a sense of things other than that this place is WAY further ahead financially/development-wise than my last few posts (Mozambique, India). Being in a country full of diamond, gold, and uranium mines with a small population makes a pretty big difference. Water from the tap is potable. Waterpressure, stable electricity, and fast internet abound. It was easy (albeit a little expensive comparatively) to find soymilk, gluten free products, and greek yogurt at the supermarket. I'm preparing myself for getting to the hospital, where apparently the physical plant is not so lacking, it just that the lab isn't always running for even basic test, no one knows how to use the brand-new ventillators or echocardiogram machine, and so much of the equiptment goes unused.

Hopefully, this trip will bring many good experiences. If I can see some interesting cases and help share some of my knowledge, and get a sense for the work going on here, then we'll call this a success.