I enjoyed this recent Tom Friedman essay

Op-Ed Columnist
The Land of ‘No Service’
By THOMAS L. FRIEDMAN
Published: August 15, 2009
Chief’s Island, Botswana


The New York Times
Thomas L. Friedman

THE LAND OF "NO SERVICE"
If you travel long enough and far enough — like by jet to Johannesburg, by prop plane to northern Botswana and then by bush plane deep into the Okavango Delta — you can still find it. It is that special place that on medieval maps would have been shaded black and labeled: “Here there be Dragons!” But in the postmodern age, it is the place where my BlackBerry, my wireless laptop and even my satellite phone all gave me the same message: “No Service.”

Yes, Dorothy, somewhere over the rainbow, there is still a “Land of No Service” — where the only “webs” are made by spiders, where the only “net” is the one wrapped around your bed to keep out mosquitoes, where the only “ring tones” at dawn are the scream of African fish eagles and the bark of baboons, where the only GPS belongs to the lioness instinctively measuring the distance between herself and the antelope she hopes will be her next meal, and where “connectivity” refers only to the intricate food chain linking predators and prey that sustains this remarkable ecosystem.

I confess, I arrived with enough devices to stay just a teensy-weensy connected to e-mail. I wasn’t looking for the Land of No Service. But the Okavango Delta’s managers and the Wilderness Trust — a South African conservation organization that runs safaris to support its nature restoration work — take the wilderness seriously. The staff at our camp on the northwestern tip of Chief’s Island, the largest island in the delta, did have a radio, but otherwise the only sounds you heard were from Mother Nature’s symphony orchestra and the only landscapes, sunsets and color combinations were painted by the hand of God.

So, like it or not, coming here forces you to think about the blessings and curses of “connectivity.” “No Service” is something travelers from the developed world now pay for in order to escape modernity, with its ball and chain of e-mail. For much of Africa, though, “No Service” is a curse — because without more connectivity, its people can’t escape poverty. Can there be a balance between the two?

For the normally overconnected tourist, the first thing you notice in the Land of No Service is how quickly your hearing, smell and eyesight improve in an act of instant Darwinian evolution. It is amazing how well you can hear when you don’t have an iPod in your ears or how far you can see when you’re not squinting at a computer screen. In the wild, the difference between hearing and seeing with acuity is the difference between survival and extinction for the animals and the difference between a rewarding experience and a missed opportunity for photographers and guides.

It was our guide spotting a half-eaten antelope lodged high in a tree that drew our attention to its predator, a leopard, calmly licking her paws nearby and then yawning from her midday meal. The cat’s stomach was heaving up and down, still digesting her prey. The leopard had suffocated the antelope — you could still see the marks on its neck — and then dragged it up the tree, holding it in her jaws, and placed the kill perfectly in the V between two branches. And there the antelope dangled, head on one side, dainty legs on the other, with half her midsection eaten away. The rest would be tomorrow’s leopard lunch, stored high above where the hyenas could not get it.

But while maintaining “No Service” in the wild is essential for Africa’s ecotourism industry, the rest of the continent desperately needs more connectivity. Eric Cantor, who runs Grameen Foundation’s Application Laboratory in Uganda, explains what a huge difference cellphones and Internet access can make to people in Africa:

“A banana farmer previously limited to waiting for a buyer truck to pass his farm to sell the week’s harvest can now use a mobile-phone marketplace to publicize the availability of his stock or to search for buyers who might be in the market or have truck transport available to a larger market,” said Cantor. “They can also compare going prices to gain more power in a negotiation. Teenagers too shy to ask parents about causes and symptoms of sexually transmitted diseases can research them privately and improve their own health outcomes. A farmer with no money who needs a remedy for the pest attacking her primary crop can find one that uses locally available materials, when they need it.”

Botswana, about the size of Texas, luckily has enough diamonds to be able to turn 40 percent of its land into nature preserves. Its urban connectivity with the global diamond exchanges enables it to maintain “No Service” in its wilderness. Zimbabwe, by contrast, has become virtually a country of “No Service” after decades of dictatorship by Robert Mugabe, and, as a result, both its people and wildlife are endangered species.

The more African countries where “No Service” can be a choice, not a fate — an offering for the eco-tourist to enjoy, not a condition for the entrepreneur to overcome — the more hope that this continent will be able to enhance its natural wonders and its people at the same time

2 wks and Counting

We visited our old friends the Slates in Lexington, MA this weekend and stayed overnight with our daughter Abby and son-in-law Chris in Cambridge. The Slates were there for us the last time we visited Africa...When in Liberia at the end of medical school, they (having a car) transported all our belongings from Washington Heights (where Columbia P&S medical school is)to Barbara's aunt and uncle's spacious home in Scarsdale. Having once lived in Washington Heights, Sydell and Alfred, Barbara's aunt and uncle, were careful to let nothing into their house, reserving space in the garage for our things and the critters they undoubtedly housed! When we returned, all was moved without incident but certainly with hitchhikers to our new home in Rosemont, PA, where I was to start my long relationship with Penn medicine. The Slates never let on that they must have fumigated their car on the way.
It's now 37 years later. On the way back to Maine, Barbara read to me from the Lonely Planet travelguide to Botswana, which primarily concerns safari travel. We will apparently be in the country when birdlife will be at its peak. An engaged and experienced birder might see up to 350 species in a 24 hour period! I guess one can apply one's OCD to any endeavor. Plantlife, at the end of the rainy season, will be "lush" (how lush can the Kalahari be?), which makes spotting animals more challenging. I'll leave this to the professionals. In any event, this will not be the time to take a "walk-about" as high grass can make critters, varmants, and predators all too available, if you get my drift. I think we'll stay in motor vehicles. This includes watercraft. The dugout caneoes featured on some "guided" trips may bring unsavory creatures (eg. crockediles and hippos) too close for comfort. This is why "zoom lenses" were invented!
My educational preparations go on. I finished "BLS" and am somewhere near the end of valvular heart disease. I thankfully found a recent grand rounds presentation on mitral regurgitation I gave, and downloaded it on my laptop. This will shorten the valve talk, as it is too long as it is, covering AS, AR, and MS/RHD.
We're still figuring out how to have ready access to cash. Redundancy seems to be the key. We'll have a Plus system credit card (they apparently don't deal with Cirrus), an AmEx card, and some traveler's checks. We've travelled enough to be secure enough. Tomorrow I start dealing with Anthem to see if we can arrange to take 3+ months worth of medications.

Invictus

Well, I finished my Power Point presentation on Heart Failure, which should be an appropriate subject. Next is Cardiac Arrest. I suspect this is a rather futile subject relative to Africa, but education is the first step to successful performance. Michelle Haas, a physician who has a background in ID (AIDs specialty) has requested a rather ambitious lecture schedule, an I have hopefully prepared adequately to meet her expectations. I am unsure how sophisticated the group will be, as there are MOs with limited post-graduate education or experience, Penn residents, medical students from many centers of medical education, and faculty, who may or may not be interested in what I have to say. I think a review of BLS (Basic Life Support)would be very appropriate for this group, but ALS (Advanced Life Support) of questionable use. I'll also spend time on Valvular Heart Disease, which is not only one of my main interests, but also pertinent to patients presenting in Botswana, who will have a certain prevalence of rheumatic heart disease and chf.
Barbara and I spent a snowy afternoon at the movies. We watched Clint Eastwood's Invictus, starring and produced by Morgan Freeman. The story of Nelson Mandela, his instictive understanding of the need to heal his country after the horrors of apartheid, the story of his incredible gift to understand the value of forgiveness and moving forward, was compelling and inspiring. The scenes of southern Africa were exciting to see and made us even more eager to experience this part of the world.

One Month to Go

One month to go! In all the anticipation of departure, we had some concern about leaving our house unattended all that time. Our daughter, son-in-law, and family (grandson and cat) have agreed to stay in the house and watch over it and all its systems. Whew.
Holiday gifts have taken a back seat to purchases for the trip. However, one gift I couldn't resist was in the golf pro-shop, a Greg Norman tie-died looking short-sleeved shirt for Barbara that had South Africa written all over it!
We have been doing some reading...Culture-Smart Botswana by Mike Main and #1 Ladies' Detective Agency by Alexander McCall Smith for me, and books by Unity Dow (a local novellist), Laurens Van Der Post's The Lost World of the Kalahari, memoirs of Quett Ketumile Joni Masire, the second Botswana president, Reasonable Radicals and Citizenship in Botswana, The Public Anthropology of Kalanga Elites (these were Barbara's choices). I think we'll both enjoy the Bradt Safari Guide of Botswana, which should come in handy on weekends.
Right now I'm preparing Power Point talks to give on the weekly conference schedule. I'll plan to emphasize Heart Failure, Acute and Chronic CAD, Clinical Utility of Echo (using ACC/AHA Guidelines), along with the basics of taking ECGs, performing a cardiac examination, and probably management of patients with valvular heart disease. I'm still teaching at the hospital, doing echo scanning and attending conferences and committee meetings. I don't know how I could have gotten all this done while continuing to practice!

December preparations

As the winter closes in, we need to prepare for the Tropic of Capricorn. The south African weather promises to be both hot and wet, although the rains may not be as severe in January as they are supposed to be currently. Nevertheless, it can't be as bad as the snow/sleet/freezing rain/high winds/thunder/lightning we are getting from the current storm which has swept in from the midwest US. I've been grabbing stuff whenever I think of a new thing we might need, and storing it in a laundry bag under my desk. The stuff includes (but not limited to): a Xenon-bulb small flashlight, LCD headlamps, bug repellant, binoculars, an extra photo flash card, 5 kg Aquasonic echo gel, batteries of all sizes, ACC/AHA pocket guidelines (preparing talks on the laptop), a multifaceted pocket tool, a bicycle cable lock, lots of Botswana-relevant books, etc. We ordered Ex-Officio travel underwear (washable and quick drying). We stocked up on LL Bean tropical wear (sun- and insect-repelling shirts and pants). Barbara bought Merrill hiking shoes similar to mine. We have hats, sun-screen, and other protective stuff to ward off the elements. I bought a "freeze-alarm" that will monitor the house temperature while we are away, alerting our family in town in case the furnace fails (this would not be good). Barbara has been creating lists and lists of lists.
We heard from Philips that the laptop echo machine I had hoped for (CX50) may not be available. Instead, they offered a HD11. This is older technology and not as portable, but will suit if the more desirable option is not available. I can wheel this machine onto the wards of PMH in that there is only one floor, but it will not be possible to do outreach echoes outside the hospital. I'll continue to lobby for the more portable option.

Preparatory Musings

Conversation with Barbara about plans for transporting medical equipment to Africa without costing an arm or a leg.

Getting Ready

This is the preface to our journal documenting our 3 month journey to Botswana, between mid January and mid April 2010. As a Hospital of the University of Pennsylvania alumnus (IM '77, Cardiology '79), I have been given the opportunity to participate in the partnership between Penn and the government of Botswana (Botswana-UPenn partnership or "BUP"), providing teaching and medical cardiology services at the tertiary medical school-affiliated facility, Princess Marina Hospital in Gabarone, the capital city in the southeast part of the country. Preparations are underway -- planning to be away from a large home during the Maine winter is daunting!  We've had our shots, had TB testing, received recommendations for insect repellant and malaria prophylaxis, obtained electical connectors to help transform 220v to 110v. We have a new laptop (do I really need 320Gb of memory?) to help us communicate, pay bills, give lectures, and entertain (lots of classical music and R&B downloads). Philips corporation has kindly offered to provide me a state-of-the-art laptop echocardiogram machine to use while there, and I'm trying to figure out how to get 10kg Aquasonic gel delivered there without costing unconsionable quantities of cash. Soon, we'll pay attention to clothing and other items suggested in the very helpful handbook provided by Penn. Less will be more, and we hope to travel light other than the above-mentioned electronics. We also have to figure out how to transport >3 months-worth medicines (insulin kept cold, Minimed pump supplies and batteries, back-up diabetic materials like Lantus, injectable Novolog, test-strips and lancets, ad nauseum). Anthem tells me they will make sure I can take whatever I need...a helpful assistance from private health insurance (an oxymoron?). We'll start posting regularly after Jan1. Happy Thanksgiving and other subsequent holidays!