Postscript

The farewell party was great, and the opportunity to see friends and housestaff delightful.

We returned home to Portland without difficulty. All our luggage arrived with us, undisturbed. Only one pottery piece, ironically positioned within much padding and inside other pieces, shattered, leaving us with 5 instead of 6 dessert bowls! The fabric, wooden pieces, and the intricate baskets and woven grass platters were unscathed. These were greatly enjoyed by our friends and family. We saved a carved wooden bowl for our real-estate brokers, who helped us negotiate the sale of our Portland home while we were away, handling negotiations spanning 3 continents (Europe [UK], southern Africa, and North America!

I miss the clinical involvement of daily patient care and echocardiography, despite being busy with readying the house for the move. The contributions to teaching and health care delivery were frequent and gave me a lasting reward. A bit of the feeling lingers as I wrote a paper describing the patients we sent to RSA for heart surgery in strong part based on the echo findings. I have helped out in a legal case, but will remain on clinical sabbatical until early October, after my leave expires.

Barbara is doubly busy, having returned to her work at the Muskie School at USM and also plowing though our belongings and old papers (we saved everything since 1983!) in preparation for the move. Our children and neices have selected momentos of Bowdoin Street that we are pleased to let them keep in their own homes.

I'm still trying to encourage UPenn to help establish a more permanent cardiology presence in Botswana, both in terms of providing HUP cardiology attending and fellow participation, and the creation of a modern echocardiography laboratory through the training of a technician.

Other remaining tasks: The paper on our 2 endocarditis patients that received emergency heart surgery was submitted for presentation at the World Congress meeting in Vancouver in July (still waiting to see if it was accepted!) and will have lots of show-and-tell sessions with the ID division and cardiovascular services department at MMC. Barbara has been asked to give presentations also. They will help to extend our memories of the wonderful past 3 months. In the meantime we have pictures, books, and the words of this blog to remind us of the meaningful, enjoyable time we spent in Botswana.

Sale Santle Botswana

Incredible - only a few more days here in Botswana and seems like a good time to think about what I will miss about here and what I have missed over the last few months from our US home. Sale santle means goodbye in Botswana, but in the typical complexity of the language, is only said by the person leaving (it translates as "stay well") and the person who is staying says to the departing person, "tsamaya santle" or "go well". All makes good sense, but sometimes hard for me to remember which role I'm in! Then there is "sleep well" travel well, etc.

So here are some random musings about what I will remember fondly. I love the names we have come across here - Precious. Luscious, Beauty, Tiny Man, Alleluia (born on Xmas), ThankYou, Grace. Wonderful sounding rolling r's (that I still cannot manage) that come our with every "dumella rra". Yes (ee) is pronounced as "aye" but is so much more than that - it is typically said with great emphasis and lots of panache, sometimes as aye rra! (yes sir). Setswana and all the tribal languages we hear are usually spoken pretty loudly with lots of dynamics. In contrast, English is almost whispered. Pale sounding in comparison.

How about those umbrellas! In the sunny midday, umbrellas shoot right up to protect people from the sun. Mostly women and girls, but even men use umbrellas for the sun. Guess, what, it really works! Lots more coverage than a hat and cooler as well.

The size of the sky here. We have been to remote areas before to witness wonderful night skies but there is something about the sky in Africa - the brightness of the stars, shooting stars, the southern constellations. As we are pretty flat here, the horizon goes on forever.

I will miss the small town, friendly atmosphere of Gabarone. We have made some nice friends here who have been very welcoming and generous to us. Compared to the rest of Botswana, this is a big bustling city, but it has more the feel of an Augusta Maine size town. Lots of people working here either for the govt, or because this is where the jobs are, but they come from all over and often go back to their home villages up north or to their cattle posts.

I will miss how Peter comes home most days shaking his head about the incredible case he has seen or laughing about some bizarre event at the hospital. Very charged up about the pathology and pleased to be providing such a needed service in both teaching and clinical care.

Trying out new stuff - whether it is the safari adventures we have had to see incredible game, birds or just neat plant life, or merely taking a combi ride to a new part of town, trying new foods, meeting people with interesting backgrounds and perspectives - it all adds up to a wonderful sense of adventure to our days here. Sometimes exhausting but still very stimulating. A reminder that most of this is probably available to us back home but until you are placed in a foreign situation we tend to stick to our well worn ways.

Now, what I can't wait for:
Our family and friends - we have missed our fam very much (and one little 3yo Duncan in particular - can't wait to get the real life hugs and kisses from them all!). Skype, email, email chats, all make it bearable but are just not the real live communication we miss. We very much look forward to seeing the friends and family who have been following this adventure (and those who have wondered - whatever happened to Peter and Barbara?).

Reliable IT - again the technology here is far better than in most places in Africa, but still quite slow and unpredictable. Much gnashing of the teeth as I wait and wait and wait some days.

Getting back to familiar routines of home and work - all the everyday mundane stuff that makes a place your home will be wonderful.

Driving myself around - we have been without a car here, and I miss having my wheels (instead of walking, taxis and depending on the kindness of friends for rides).

Regular exercise. While I have been walking most days, I miss the gym (hard to believe) and both of us feel the need for more of our routine exercise days. BT and Mary - will be waiting for you on the blvd and I believe Peter plans a return to Woodlands golf asap.

We have learned and accustomed ourselves to the African pace - which is far slower than the type A American style of talking, moving, responding, making decisions. But it will be refreshing to get back to good old American moving right along!

We are off in a few hours to a farewell event hosted by our friends Gordana and Branco Cavric. Should be fun and will fill you in on the details later.

As the week closes...

I was a bit rueful, despite the inevitability, of the local distributors removing the Philips HD 11 echo machine. I have learned to operate the device pretty well, adjusting to many different body types, chest wall thicknesses, lung interference, and levels of illness in echo subjects. In addition to creating the images, doing an echo is a bit like telling a story...the operator catches glimpses of pathology, and finds a way to expose and illustrate the abnormalities with off-angle shots, images taken from many different perspectives, use of a variety of techniques such as color and spectral Doppler, tissue Doppler, zoom, freeze, colorize, gain, compression, and many other tricks to optimize the information to take from the study. My hat's off to the many talented and accomplished echo technicians at MMC and CCM who spent hours coaching me so that I could perform studies independently to augment clinical assessments heretofore available in Botswana at the bedside only.
The pathology uncovered here is astounding, magnified at times by underlying immuno-incompetence due to retroviral disease, and at other times through inadequate access to competent cardiac care. There were other patients with amazing findings that would be seen (rarely) anywhere. These include: an unfortunate 21 year-old woman 3 years post above-knee amputation for osteosarcoma (a terrible tumor) who now had a left atrium full of obstructive metastatic disease, a patient with right atrial myxoma (an unusual location for this type of tumor), 2 patients with endocarditis that needed urgent open-heart surgery (one with severe mitral incompetence due to valve abscess and perforation, and another with a ruptured sinus of Val Salva aneurysm, localized aortic root dissection, and aortic valve perforation with a large vegetation, all causing a subpulmonic VSD and severe aortic incompetence), and 7 patients with large probably tuberculous pericardial effusions, 6 of whom required drainage (by echo technique). The frequency and severity of pulmonary hypertension and right-heart failure made one jaded about levels of pathology that in Maine would cause us great concern. I found congenital heart disease, rheumatic disease, and severe pathology in patients who had previously undergone open heart surgery in South Africa. What an experience!
The opportunity to teach the Botswana residents was another treat that provided great satisfaction. They are a smart, talented group of men and women, who are skilled in handling HIV/AIDS and its common complications, but lack some basic information and skills that will allow them to grow. The concept of differential diagnosis as a guide to choosing proper testing and treatment strategies is one that needs to continually emphasized. There is small group of dedicated employed physicians, contract physicians, and BUP (Botswana-UPenn Partnership) doctors who have these young people in their hands to mold into mature and competent practitioners. I am proud to have participated in this vital process.

Franschhoek

The Franschhoek valley is a gorgeous slice of southern Africa. The last elephant was seen leaving the valley is 1850, and if you didn't know you were on this continent, you'd swear you were in Provence or northern California. We toured 2 vineyards. The first was Boschendal, a large centuries-old winery with many low buildings more than 150 years old, converted to tasting rooms, restaurants, and production facilities. The tasting of 5 varietal wines occurred outdoors, on a sunny breezy day surrounded by lawns and plantings. We then drove to the other side of the vineyard where a large garden party (pris fixe) was in progress (Easter Monday is a national holiday); we had a lovely simple lunch at the alternative spot of salad with bacon and cashews, and fish and duck pate with brown bread.
We then visited the Graham Beck vineyard, which was the exact opposite to the ancient flavor of Boschendal. The Beck facility was spacious, also, but modern, studded with garden sculptures, and a lovely tapestry in the main hall. We tasted a very nice Portage there, which we had at dinner, at iCi, one of the restaurants at Quartier Francais, which produced the best dinner of our 3 month stay in Africa!
Tomorrow, it's back to Cape Town airport and then return to Gaborone via Johannesburg. Five more days of work, and then back home. This visit to South Africa was an excellent way to make that transition to familiar surroundings.

Our 39th Anniversary!

Lots to do today. We got up early, ate breakfast (The Cullinan has a really excellent buffet, with every variety of breakfast style one could want, and my favorite, fresh-squeezed OJ!) and checked out of the hotel. It's Easter Sunday and the roads were fairly empty, so driving the the Royal Cape Golf Club was easy. The club dates to the 19th century, and the layout was great. The design is a parkland course,lying beneath the mountains that ring Cape Town, relatively narrow with mature trees lining the fairways, and water hazards that were obviously drier than during the height of the South African summer. The fairways were flat, so walking 18 holes was a pleasure. The rental clubs were many steps above what we had available in Botswana or Zimbabwe, and were easy to play with. I even birdied 16! The wind was near gale-force, probably over 30 mph, so down-wind holes were definitely easier than holes into the wind. According to other golfers, "this is the windy season!"
After lunch at the course, we drove to Stellenbosch, in the western cape wine district, and are staying in Franschoek nearby, in a nice little hotel on the main drag. We'll walk down the street to a nouvelle cuisine restaurant, and I think we'll try a little South African wine! Actually, we've been drinking wines from this country during our entire stay in southern Africa, and are impressed with the quality, value, and variety of the choices available. We were able to make reservations at a nearby restaurant, Reuben's. Franschoek and this whole area are very much in the flavor of Napa/Sonoma with much more impressive mountains. We realized that now in early April, we have hit the harvest season (translate early fall in the southern hemisphere) and there are gusty winds, falling leaves, the whole harvest picture! We had a wonderful meal - our best of three months. Peter had a terrific rack of lamb and I had a lovely Cape salmon and shellfish dish. Wonderful flavors, great SA wines, and all for about 1/2 of what a high end meal like this would cost in California wine county. This is a strongly Afrikaans area - the first language on signs and speech is Afrikaans and then English, but otherwise you might find it heard to believe you were in Africa, if your only impresson of Africa is jungle and wildlife. Southern Africa is wonderfully multi-dimensional and South Africa has a very complicated and multifacted composition. We have only seen a small slice of this country and perhaps we will return to see other sections of SA that are beyond our itinerary this time. A wonderful anniversary day - full of delightful scenery, fun and new adventures with my soulmate!

Two Oceans Marathon and Jazz Festival Headaches

Cape Town is rocking, and transportation is difficult because of all the recreational activities! As Table Mountain was enshrouded in clouds, making the ride to the top fruitless, we decided to go to the Kirstenbosch National Botanic Gardens. This is the oldest garden of its kind, displaying indigenous plants in a gorgeous setting, under the other face of Table Mountain. Leaving the hotel was difficult, due to streets blocked off for the Jazz Festival. We finally found the route south to the Gardens. Unfortunately, all access to the place was blocked by a huge clump of marathon runners, forcing us to crawl past the turn-off, and head back into town. We found a bookstore to prowl through after a latte break.
We went down to the waterfront for lunch. Fully fortified, we made our way back to the Gardens, this time, with the marathon over, successful! The place was lovely, laid out on sloping land leading up to the base of the mountain. The landscaping is meticulous, with manicured lawns separating large plantings of indigenous species of trees, shrubs, flowers, and grasses. Interspersed were beautiful contemporary sculptures by African artists.
We made our way back to the hotel, had dinner at the waterfront (the weather is definitely changing, and autumn has arrived to the southern hemisphere). We dined outside at a nice fish restaurant, and although we were surrounded by glass walls and "warmed" by portable gas heaters, we froze and were happy to jump into bed upon return (by shuttle) to the hotel!

A Good Friday

We left the hotel after a great breakfast buffet, driving south toward the Cape of Good Hope. We drove through seaside communities that reminded us of Marin County: Hout Bay, Simon's Town, and Scarborough, headed toward the Cape of Good Hope Nature Preserve. The fog hung tough on the eastern part of the peninsula, and we found the drive more pleasant driving down the western border. The skies there were crystal clear, without a cloud except for mist hanging over one of the mountains north of Cape Point. We climbed up to the lighthouse at Cape Point, constructed in the late 19th century at great risk and effort. Unfortunately, in fog, the light could not be seen, and so a second lighthouse was built lower along the shore with more benefit to the wayward seaman. The views were striking and made the climb worthwhile. We also visited the colony of African penguins in a town called "The Boulders" on the east side of the peninsula south of Simon's Town. The birds are protected, as this is their only habitat on earth. They were incredibly appealing, as penguins tend to be for human visitors.
We were pretty tired after a long day of driving and hiking, and decided to have a simple supper in the hotel bar. We hope to visit Robben Island tomorrow, but the tickets are sold out. Perhaps there will be cancellations.