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.

Cape Town Arrival

With Easter approaching, and with a long weekend providing another opportunity for travel away from Gaborone, we flew to Cape Town via Johannesburg. The passage through the JoBurg airport was somewhat enervating. After deplaning, we picked up our luggage (booked through to Cape Town) and had to drag it several blocks worth to the area where luggage was to be picked up again by the airline and sent on to Cape Town. Unfortunately, the windows were closed, and we had to take the bags up 2 flights to the ticket counters and resend our luggage to be put on our plane to Cape Town. The airport scene was hectic, including an elderly woman in a wheel chair who had spilled all her belongings and purchases around her, blocking access to the ticket counters. With the clock ticking, we got the luggage sent off, passed through security once again, and then made it to the bus which carried us at least a mile to our waiting Airbus (300 passenger...we were in row 56, with another section behind us!) We arrived in Cape Town without difficulty, and rented a Toyota Yarus from Avis. The drive to the hotel was uneventful except that I had trouble remembering that the turn signals were on the right side of the steering wheel. It seemed that every time I wanted to change lanes, I activated the windshield wipers on the left side of the steering wheel!
This evening, we went by hotel shuttle to the waterfront, where we ate at a Belgian fish-house, Den Anker. We sat by the docks, overlooking the town on the other side of the harbor, with the smell of the sea that we realized we have missed while in the deserts of Botswana. Barbara had fish chowder and mussels, while I had lobster bisque and saffron-braised Kingslip, an African salt-water fish species. We are looking forward to taking in some of the concerts of the Cape Town Jazz Festival, which will be running this weekend. We got a preview, as our hotel is across the street from the Civic "Centre"; we crashed a cocktail party at the center museum and learned that outdoor concerts will be held this weekend across the street from our hotel!

Holy Week

The week has been very productive thus far, and today was no exception. I was shadowed by Diana Dickenson, MD, who runs the "Independence Ave. Surgery" and who has been a driving force in HIV/AIDS diagnosis, treatment, and prevention in this community. Every October, she helps organize an AIDS conference that is important in the ongoing fight against this infection which is robbing the country of most of an entire generation. She wanted to know what exactly I do here. We reviewed the recent TB pericarditis patient I tapped, and, after nearly 4L of drainage, the catheter is ready to pull out. I'll do a follow-up echo soon. She pointed out the characteristic rashes of moluscum contageosum and herpes simplex infections. The dermatology fellow was informed and will consult.
We rounded on the postoperative valve-replacement patients being treated for infective endocarditis (4 wks of IV antibiotics for each). Both are doing quite well, but one, with a Hickman central line, has had to get her drugs via a peripheral IV because of the nurses' reluctance to infuse medicines through this port.
In the afternoon, the chief of medicine asked me to assess her friend, a local lawyer with probable thrombophebitis of the right lower leg. This problem led his doctor to discontinue statins and substitute "red rice yeast" to lower cholesterol for fear that there was a relationship between the statin and the swollen leg. I ordered an ultrasound and will anticoagulate the patient if DVT is proven. He also will restart the statin.
The former PMH superintendant asked me to see 2 patients, one with a pulmonary, not cardiac problem, and another who had an abnormal ECG and hypertension; the meds for BP had been stopped by his pharmacist because he had become normotensive. I got him back on his antihypertensives.
I also was asked by the surgeons to do an echo on an elderly man with an abnormal chest XRay (a "mediastinal mass"), which turned out to be a >7 cm aortic arch aneurysm. The pathology here is astounding.
Tomorrow we go to Cape Town and the wine district for the Easter holiday. More on this to come.

Holiday Time!

Back to work. We had another patient with a huge pericardial effusion (probably 4L), which allowed another opportunity to teach a resident echo-guided techniques for tapping the fluid, almost certainly tuberculous. The residents are enthusiastic about learning to use their skills (all are excellent IV starters, blood drawers, para- and thoracentesis performers) to do this technique....much of the anxiety about where the needle and catheter are going is relieved with seeing the effusion and obvious entry point by direct echo imaging. I followed up by giving another of my Monday PM talks on pericardial disease and pathophysiology of tamponade. Pictured here are 4 of the 5 residents (I'm the pale one in the back) with whom I have enjoyed working over the past 2.5 months.
We spent the evening at Matt Dasco's house (he's Penn Internal Medicine Faculty, and his wife Premal is a Baylor-employed internist) celebrating Passover with Gaborone's most ecumenical seder (4 of 20 participants were Jewish!). All had a great time. Barbara's matzoh-ball soup and sponge cake were greatly enjoyed and Dayenu was a big hit!

Johannesburg and Pretoria

Our friends Gordana and Branco Cavric, asked us to go along with them this past weekend driving to Johannesburg and Pretoria. Gordana is the chief of medicine at PMH and her husband is an urban planning professor at U of Botswana. They like to drive there and visit "the big cities" and thought we'd like to come.
The drive to JoBurg is 4 hours (sometimes at 200 km/hr!). We stayed in the northern section called "Fourways" in a charming country house with 2 large Bull-boer dogs, a very needy cat, and a fish pond full of hungry Koi. After breakfast on Saturday we set off for the "Origins Museum" at a local university, which had excellent exhibits regarding prehistoric man in Southern Africa, and a great set of videos describing the life of the San, the south African bushmen who live throughout the region.
We travelled on the the "Old Fort", the prison on Constitution Hill which formerly housed criminals mixed with political prisoners, in a harsh and cruel setting, blacks and "colored" separated from whites, with major differences in food, treatment, and survival. The Constitutional Court is on the grounds of the demolished prison, a symbolic demonstration of the present erasing the past. Somehow, I think the laws may have changed, but personal behavior and attitudes are slow to evolve as quickly.
Johannesburg is a huge city, 5 million inhabitants, built on a collection of hills, with huge driving distances from section to section. The old downtown has moved to a new section surrounding "Mandella Center" (named after you-know-who) and the malls in this place are very high end and with few vacancies. In addition, I was struck by the never-ending cavalcade of auto dealerships, all premium models (BMW, Audi, Mercedes, Lexus, Ford, GM, Toyota, etc). The rich collection of commerce must speak for a prosperous economy.
Dinner Friday was at the "MonteCasino", a faux Italian mall and casino that was very reminiscent of Las Vegas and Epcot combined. Saturday night we went to "Sophia's", and homage to Sophia Loren, who combined Greek heritage with Italian panache and beauty. We discovered ostrich and gamesbock carpaccio at MonteCasino, and beef carpaccio at Sophias, while Branco drank grappa. I settled for Jack Daniel's.
Sunday included an art show and a drive to Pretoria, the national capital, a very manicured appearance and a somewhat smaller, more intimate feel than JoBurg had.
We drove home with a big sky full of thunderheads and scattered rain showers. The border crossing is cumbersome but generally benign. It was a great weekend and the Cavrics were wonderful to have put out such effort to help us experience nearby RSA.

Signs that it's time to go home

1. I have finally run out of antiperspirant and shaving gel on the same day. Trust me, never try to go to the local market on a Friday afternoon...it's packed! Trying to locate personal items in the crowded shelves at the corner Spar is a challenge. There are loads of body washes, body cremes, and even roll-on deodorant-antiperspirants, but no familiar brands. And no shave creme at either of the markets! I'll have to keep looking for this item.
2. Echo requests are coming in daily. It's time for an echo tech to be trained, and to establish a modern laboratory with the equipment currently available.
3. My car battery (9 years old) has died and the BMW won't start. I have made an appointment the day after we return for a new battery and 90,000 mile inspection, oil change, and other maintenance issues. I'll then splurge and get the car detailed.
4. We are in the process of selling our primary home in Portland, and may have to vacate in June, 6 weeks after coming back. This task seems enormous, considering the 27 years of contents to deal with!
5. The damage from a windstorm in Harpswell had to be dealt with. Our neighbor, Mark Lieberman, is taking charge of the downed trees, after our daughter and son-in-law, Emily and Leigh (with Duncan's help) took care of electricity, security, and supervision of driveway access to the T-Ledge house.
6. The Philips corp will be repossessing the echo machine they loaned me in 2 weeks, unless the hospital buys it, or Philips donates it to the hospital or UPenn. I hope it will stay, as the machine is easy to use and has many of the features of more modern machines.
7. The local liquor store is out of Tanqueray. I finished their supply over the past 2.5 months (It really wasn't that many bottles).
With all of this swirling in our brains, we feel drawn back home. Three months is a long time to spend away from family and familiar surroundings, no matter how interesting and exciting travel and immersion in foreign culture seems.
In the mean time, this weekend we will visit Pretoria and Johannesburg, RSA. Over Easter we will be in Cape Town and the Franschoek wine district. We'll be home 10 days later. It's time.

Cardiology is here to stay

I believe I have established a needed service here. The residents and practitioners from all over the hospital call and request consultative and echocardiographic services for their patients. Today, a patient from Lobatse was referred for an outpatient echo. A patient was sent from the outpatient clinic who had severe AR, severe MR, TR with evidence of moderately severe pulmonary hypertension who will need valve-replacement surgery. A patient with an ST-elevation MI airlifted to South Africa returned with a new stent and relief of post-infarction angina. An elderly man with complete heart block returned from the same hospital with a new pacemaker, and since cataracts were discovered, restored vision as a result of cataract extraction and lens implant. I am working with the echo companies to fund the 3 month training of an Xray technician to learn echocardiography, so a modern echo lab can be established here at Princess Marina Hospital. If this can happen, I will feel that I have made a difference here.

Okavango Delta

On Friday morning we departed for the Okavango Delta in NW Botswana. We once again flew to Maun, but because the delta is a flooded area with camps on scatttered dry spots, we had to take a puddle-jumper 6-seat single prop plane into our camp, called Pom-Pom (which means "soft place" in Setswana). We were welcomed by the staff, who stood in front of the entrance singing a lovely Setswana song of "Dumella". The lodge, like Makgadikgadi, consisted of a central open-air pavilion with several self-contained tents surrounding the main building. This place was up-scale, with "en-suite" bathroom and out-door shower contained within the protective stockade fence. We had electricity after dark, a luxury in remote Africa off the grid!
After arriving, we had the afternoon to "siesta". We then met our guide, Paul, and tracker, Dicks, who took us out on a game drive at 4pm. It was an exciting ride. We saw an ever increasing variety of birdlife, which thrived in the wetlands created by the Okavango River which flows from the northwest and essentially empties into the sands of the Kalahari. The water levels rise in the late "summer"; the water in front of our camp had increased in the past week to allow maccoro canoes to be launched right from our beach, rather than having to transport them 20 minutes away to the nearest site of water access. We came across leopard tracks and found the cat resting near a freshly killed and recently eated kudu, the site of which was given away by the buzzing of flies on the carcass. At sunset we stopped for drinks and a view of the beautiful skies of western Botswana. The guides were looking out for Barbara and me...white wine and Jack Daniels! Dinner back at the lodge was first-rate, with excellent food, great variety, and thoughtful selections.
The tent was quite comfortable, and I slept great. Barbara did a lot of reading.
The next morning, after a light breakfast, we climbed into maccoros, which are modern replicas of the traditional dugout canoes indigenous to this area. I sat in the bow, with Barbara in the middle, and Dicks stood in the stern poling (the water was less than 1m deep, and in the reeds was safe from both hippos and crocks). The trip, which lasted all morning, allowed observation of a rich display of birds and scenery. The afternoon game drive was notable for lots of wading birds (our first flamingos, yellow-billed storks, and spoonbills), wildebeest, zebra, giraffes, a rare elephant, impala, leechwe, kudu, and lions (watching a sleeping lion is a moderate thrill at best).
Sunday morning allowed us to go on a long walk with Paul, who was a font of information about animal tracks, plants, birds, animal behaviors, termite colonies (the hills were especiallly impressive in the Delta). He carried a loaded rifle, but we never felt in any danger.
We flew back to Maun, and then on to Gaborone. The weekend was restful, and a great getaway which provided a chance to experience another region of this beautiful place.

Lobatse

This morning I walked over to the UPenn office at 0630h to meet Mike Pendleton, MD, a FP from Oregon who, like me, grew to detest night call and came to Botswana to help teach in the Botswana-UPenn Partnership. Mike primarily performs medical outreach. The primary sites are Mochudi (where I went last week), Lobatse, and Kanye. Today was Lobatse, a town about 40 km southeast of Goborone. We arrived at the Althone Hospital (the oldest in Botswana, built around 1922), used initally as military barracks. We attended morning meeting, which began with a prayer (recited in quick-time English by someone in the back row). There was no song, much to my disappointment. Patients were presented by the nursing matron sitting at the front. The doctors took little part in the discussion, and the scrubs-clad woman next to me seemed more intent on working through her cell phone messages. Curiously, there was a land-line phone on the main desk, which rang several times during report. The phone was answered, and a discussion ensued which rivaled (and obscured) the simultaneously occuring medical discussion in the same room!
Thereafter I was directed to the male medical ward, where several patients with cardiologic issues were housed, 8 to a cubicle. There were some interesting questions (rhythm, heart failure, and physical findings) in a few patients, among several patients without heart disease. I was even asked to look at the right thigh of a 27 year old HIV and TB-infected man who had moderate sized papules (somewhat pustular) and its anterior aspect, with firm lymph nodes in the groin on the same side. I thought it likely was extrapulmonary TB, and encouraged aspirational samples from both the papules and the groin nodes. For a cardiologist with little TB or HIV experience, I was gratified when the other physicians agreed with my assessment.
I spent the rest of the time with Dr. Pedro, a general internist from Cuba in his mid-late 50s, on a 2 year contract with the country held by the Cuban government. Cuba won't allow family members to travel, so he, like the Cubans in Gaborone at PMH, must leave their spouses at home. This would not work for Barbara or me. Dr. Pedro had collected a number of consults for me to see in his office, one of whom will see me Tuesday at PMH for an echo.
Today is the intern match day, and the students here are anxious, despite already knowing that they all were matched somewhere. We find out specifics tonight, and will be helping to host a cookout for the students and residents tonight, also partially hosted by UPenn faculty. I'm certain there will be no long faces among the prospective house officers. Plenty of beer will be available for anesthesia.
Tomorrow, we're headed back to Maun, to be transported by bush plane to Pom Pom Camps in the Okavango Delta. We'll have plenty of details after the weekend.

Back in the Saddle

After returning from our safari weekend, we returned to Gaborone and hospital routine. The director of the Botswana-UPenn Partnership, Harvey Friedman, MD, the chief of Infectious Disease at the U. of P. hospital and research ID doctor has come for the week and we have had the opportunity to share space, memories, and philosophies over dinner and wine.
The work in the hospital has changed, in that my presence is no longer an anomaly, but I am depended upon to help refine diagnoses, direct management, and objectify with echo cardiologic issues and emergencies. In the past day I have sent a patient with an ST-elevation MI to Johannesburg for invasive management (this was in the absence of 2B3A infusions, IV heparin, IV nitroglycerin, clopidogrel, etc), diagnosed apical mural thrombi in an elderly woman with embolic infarction of a foot, and ruled out cardioembolic source in a young patient with a stroke. Once I am no longer here, these services are in danger of lapsing. I have 2 ideas to allow them to continue. One is to have the device providers underwrite the training of an Xray technician to become an echocardiography technician. He/she could return to PMH, establish an echo lab, using the GE machine (Vivid S6) and/or the Philips HD11 (if the company would sell it to the hospital for a good price). The doctors here could be trained through CME to learn to read studies provided by a competent echo technician. The second is to encourage 2nd or 3rd year cardiology fellows to come here for 6 week rotations; this would be especially beneficial for the noninvasive fellows. They would be busy and stimulated by the breadth and depth of the CV problems here. I would encourage either UPenn to sponsor this endeavor, or perhaps the American College of Cardiology to fund it, similar to the program created by the American Academy of Dermatology, who sends a fellow here every 6 weeks. I am waiting to hear back from the vendors with respect to my first idea. It could make a huge difference here.

Makgadikgadi

On Friday morning, we flew to Maun in northwest Botswana, the center of safari activity in the country. We were transported by Land Cruiser over paved and dirt roads to Meno A Kwena, a small safari lodge in the Makgadikgadi National Park near the pans (Nxai Pan [pronounced N-click-ai] and Makgadikgadi Pan, salt-sand flats that are remnants of the great lake that covered this territory thousands of years ago, now part of the great Kalahari desert. The lodge is on the Boteti river, which has had water for the past 3 years after 20 years of severe drought. As a result, the plant life is changing, and animal populations are migrating as they did decades ago.
The camp is quite primitive but all creature comforts are provided. We slept in a tent which was well bug-proofed, with mattresses, comforters, oil lamps, and water warmed by the sun. We had a flush toilet and an outdoor shower. We were steps away from the main lodge. Our tent was protected by vertically arrayed tree branches that kept critters away from our compound (we thought). There was even a rock-encircled "plunge-pool" which was a god-send for hot afternoons after safari.
The meals were served in a dining tent. We were the only guests this weekend, so it was just us, our guide (Max) and 2 volunteers for an NGO called "Water for Life" which helps support the camp. The food was great, prepared by two Botswana women who, before each meal, would announce the choices, and then proclaim, "Ladies first!"
The first day we spent getting settled, and then walking down to the "hiding place" set on a low ridge above the river, where we watched elephants bathe below us. After supper, we went to bed, and since the night was warm, we left the windows open , screens intact. At 2AM, we were awakened to hear loud munching and snorting just outside our right window. This went on for at least 30 minutes. It was an elephant grazing in the bushes on the perimeter of our stick-protected compound! Sleep was impossible. After dumping a ton of stool and eliminating gallons of urine, it moved on. Thereafter, the baritone dronings of a giant eagle owl filled the night air. P slept better than B.
The next day, we took an 11 hour game drive. The desert is still relatively green, and in early autumn, the grass is beginning to brown up. We saw tons of elephants, giraffes, many hippos, impala, kudu, and a huge variety of birds. We returned to camp after a fulfilling day.
Dinner was great (they had Jack Daniels!) and we went to bed with elephants and hippos dancing in our heads. Literally. The elephants were having a pool party in the river below us for most of the night, and were chased away by a bellowing hippopotamus at about 4am. P slept much better than B.
Sunday morning we took a walk with our guide Max down to the river ("Jesus! This is GOOD!" was Max's frequent refrain). We were armed only with an arrowhead on the end of a stick, but really were protected by Max's extensive knowledge and experience with the animals and understanding of how to react to their presence. We studied Cape Buffalo tracks, elephant leavings, zebra and wildebeest skeletons (lion leavings), plants, birds, and geology. It was a great morning-long lesson.We drove back to Maun after lunch and flew to Gaborone in the early evening. This was a great opportunity to see the geology and wildlife of a part of Botswana not frequently visited.

Beyond Gaborone

This was a busy day. I was picked up at 0640h by Matt Dasco, MD, one of the UPenn clinical faculty who has an important role both in hospital teaching at Princess Marina but also in outreach. Today was our outreach day, spent in Mochudi, about an hour north of here. We arrived at the Deborah Retief Memorial Hospital in time for morning meeting in the Willie Neethling Hall, a room the size of a large dining hall. We sat around a line of finely finished tables with inlay, the medical staff and nursing staff all meeting together at the beginning of the day. The woman next to me, a soprano, began a song with Christian motif and Setswana harmony, with all present joining in. Thereafter, she led the morning prayer. Once these were completed, the nursing matron read the previous day's report: how many patients were admitted, how many infants were delivered, and, in great detail, the details of a stillbirth ("macerated infant") which engendered a great deal of discussion, including suspicions by the physician in charge (a Ugandan with a great barotone voice and intuitive questions) that the baby was in trouble as much as 3 weeks before delivery. Thereafter Matt presented an excellent talk to the staff on HIV infection and bone loss.
A petient was brought to the OPD for me to examine, a young woman who I suspect had primary pulmonary hypertension. We made rounds on the female ward, doctors and nurses reviewing findings in concert. I was struck by the communal approach to patient care, much different than the somewhat strained relationship doctors and nurses appear to have at Princess Marina...they seem to exist in different orbits and intersect primarily through written communications in the patient's chart. The Mochudi hospital seemed to have its act together better than Marina, including the fact that the beds were numbered, so patients could be identified by bed number, as opposed to the Marina approach of calling out the patient's name within the cubicle (hoping the patient was awake or able to communicate back!)
This evening, we attended the Ladie's #1 Opera House (a local theater company in southeastern Gaborone founded by Alexander MacCall Smith). We dined outdoors on wart-hog stew (called "venison") and lasagna under the stars. Thereafter, we trooped into the production (about the size of the Waynflete auditorium): the only seats available were in the front row. We lucked out and sat up close! The performance was a depiction of the wildlife of the Makgadikgadi, the salt pans of the Kalahari 7 driving hours north of here. Five men danced, played inventive instruments, and imitated giraffes,flamingos, elephants, wart-hog, kudu, leopard, lion, hyenas, vultures, and the people of the Kalahari. We were greatly entertained and enthralled. The dancing and singing were excellent.
Coincidentally, we are traveling to the Kalahari this weekend, and will be staying in Makgadikgadi; we hear that at this point we hold the only reservations, and so should have the full attention of the staff and guides!

Historic Day

Today I performed the first transesopahageal echocardiogram ever in Botswana. A patient was sent from up country with an expanded ascending aorta, and I was asked to exclude the likelihood that it was due to an aortic dissection. The GE Vivid S6 machine that was left here by the CT surgeons from Mauritius (they did two valve replacements here at PMH prior to my arrival) had a TEE probe (both adult and pediatric!) waiting to be used, and when I got a call from a doctor up country for this indication, I responded. Once again, it was Little Red Hen syndrome. I had to find a place (the endoscopy "suite"), the meds (for sedation, prevention of excessive salivation, analgesia, and simple things like a tongue blade with topical anesthesia, the care of the probe (cidex cleaning and drying). Everything went fine, and the referring doctor was delighted to have the results (no dissection).
The day was busy and included consultation on a patient with heart failure, who had a spectacular cardiac examination and turned out to have a congenital heart problem called Tetrology of Fallot. I am getting jaded...I am almost expecting incredible pathology every time I am referred a patient for consultation!

Far away

It's not easy trying to remain in control for issues and problems that occur at home. Tonight, Barbara has been trying to communicate with colleagues at USM regarding research issues, and at the time of the intended phone meeting, Skype malfunctioned, and we had to rely on the cellular phone connection to allow communication. Not a happy moment.
I also had malfunctions at the hospital, where my Power Point lecture decided to stop working in the middle of a particularly beautiful example of pericardial tamponade. Oh well, such is the life of tech-dependent types hoping their technology continues to provide adequate support.
Medically, the day was as usual, impressive. I was asked to consult on a patient with fever and dyspnea who had precordial thrills and on echo had infective endocardiitis, a large arotic valve vegetation, a rupture of the interventricular septum, and severe aortic regurgitation. Just another day at Princess Marina.

Social Gaborone

I have been taking Friday afternoons off, and after consulting on another patient with peripartum cardiomyopathy in the morning, got in the pool for a brief swim after lunch. We were invited to a dinner at the home of the President and Vice Chancellor of the brand-new Botswana Institute of Science and Technology, K.K. Bento. We had met at the Wildebeest roast 2 weeks ago, and developed a cordial relationship. He was from Florida, had a doctorate in civil engineering, and had been engaged by the new university to help build the campus in a town 1/2 way to Francistown, the original home of the current national president. The administration is only now being assembled, before hiring a faculty. The dinner was in honor of the new CFO, who was a woman from Canada who had been in Qatar for the past decade, working for a branch of a college from Newfoundland. Parenthetically, there appears to be a trend in American universities establishing foreign outposts...Cornell Weill has a medical college in Dubai! We were struck by the willingness of expatriots to spend years, sometimes decades, in foreign lands where they represent a distinct minority. They form a social life there that is heavily, but not exclusively, foreign-born. This goes for people from elsewhere in Africa, also. While there are many people in need who are economic refugees and who come to Botswana from deprived locales like Zimbabwe, many come for other opportunities, mostly professional like the two faculty members profiled above. Today, in an open market, we met a young woman from Kenya selling west-African fabrics and wooden carvings; she said that people expect her to be able to communicate in Setswana, where the only common language they really share is English!

PMH Needs

We started the day reviewing a very interesting case of disseminated tuberculosis in morning report. The case had been a conundrum, and review of the data and autopsy findings were very elucidating.
I am working to advance echocardiography at Princess Marina Hospital. Not only am I doing an average of 4-5 echoes/day (thanks to MMC echo staff who diligently trained me) but the value of objective data in patient diagnosis and management has been exceptional. I talked with the equipment distributor for cardiac ultrasound and ECG monitoring, and I believe that the HD 11 machine I have been using could be acquired by the hospital for a very reasonable fee. I also have identified a radiography technician who is eager to become an echo tech, and hope that the electronics distributor will be willing to sponsor a 3-month training opportunity for her in South Africa. This would allow a permanent high-quality echo lab to be established at Princess Marina Hospital, which would raise the level of cardiology services here.
On the home-front, we're making plans to go to the Okavanga Delta next weekend, and are eager to see another face of Botswana, very different from the Chobe environment. This is a part of an inland waterway that floods each rainy season - the birds and wildlife are supposed to be fantastic. We will fly to Maun and then take another light plane into the camp. We are benefiting from being here during the "green season" when rates are somewhat lower and we qualify as "residents."

Half-way mark

It is hard to believe that we are about 1/2 way into this adventure. In many ways the time has flown by. We still have lots more we want to do and see in this corner of the world and will try mightily to fit it in before April 15 rolls around. Today seems like a good time to take stock of what we have learned so far, about ourselves, Botswana, travel, living outside the US, etc. So here is my list:
1.We have discovered birding! The birds of southern Africa are beautiful, easy to spot, very colorful and a wonderful way to look into the ecosystem. For many years I watched my sister and brother in law, Roberta and David, pursue birds all over the world and did not get their fascination. At first, I was looking at the birds here kind of as a proxy for my dear sister, but then the birding fever caught hold. We have purchased bird guides, make lists of what we see, and are always looking up. This is clearly a dangerous hobby for anyone with anal-compulsive, listmaking tendencies. Anyway, it is great fun and the colors of birds here are off the charts.
2.The world has shrunk; the world is vast. So how do you hold on to this contradiction. Clearly, all this technology connects everyone not matter where in the world they are. We talk,skype, and IM with family and friends. In many ways we do not feel far away. The NYT home page is still a click away! However, there is a huge divide once you step away from the IT and look around you at a piece of the world, particularly outside of Gabarone that is untouched by many of these advances and where people live in a manner that is very different than the west. In some ways the IT is kind of a tether to what is comfortable and reminds us of home. It has also made it possible for us to keep working and communicating with you all.
3.Setswana is a hard language! I felt a little better about my slow progress once I read that Setswana is one of the Bantu languages and this language group is unlike virtually any other language family in the world. The other extremely difficult language is that of the San people (bushman of the Kalahari) who are known for the language with all the clicks!
4. Greetings matter. I am reminded of this daily as I make my way around Gabarone. Most people greet you or respond to your greeting with a dummela mma/rra, followed up by a whole how are you doing exchange. This is all before you get to your question, request. Some of the young folks may not mind shortening it up, but it is quite rude to rush into a conversation without the niceties.
5.People are people, and relating to the people of southern Africa is easy and rewarding. Working with men and women from this part of the world is enjoyable. They have as much to teach us as we can for them.
So that's all the musings for today.

Victoria Falls

We were picked up on Monday a.m. in Kasane and driven across the border to Zimbabwe - just a short 1/2 hr. drive. We had heard lots of stories about Zimbabwe - the political situation remains unstable, their currency is worthless (everything is now in US dollars) and people are desperately looking for any opportunities for cash. Zimbabwe used to be known as the breadbasket of Africa, had wonderful health care and great parks. Everything has changed of course and the people we spoke with were very frustrated with the Mogabe leadership and delighted to have tourists visit their country. We were in Victoria Falls to see the falls and stay one night at the historic Victoria Falls Hotel, which overlooks the fall. This 100+ year old hotel is a tribute to the British colonial spirit. The art work, posters, furniture all speak to the good old days when the Empire ruled - a step back in time, but still kind of neat to see it still, all spit and polish, afternoon tea on the veranda overlooking these incredible falls, all the staff dressed up. Outside the hotel, a bit of a different story and we heard pleas from all sides - I could have traded my holey sneakers for all kinds of stuff and we were offered "trillions" of Zimbabwean dollars - a kind of worthless souvenir. We braved the curio market where the most aggressive sales pitches are made and managed to buy some textiles - batiks and handpainted wares that were nice and light! The falls were very impressive, made even more beautiful by a rainbow that appeared as we reached the viewing platform. The falls stretch between Zimbabwe and Zambia with several islands in the middle. The roar from the falls can be heard from far away and there is permanent cloud of rain/mist that stretches far in the air over the falls. Quite breathtaking. While the adrenalin junkies go out for bungee jumping, rafting down the Zambezi, and all kinds of wacky extreme sports, we opted for another pastime. Yes, Heidi, we did not let the opportunity fail to add one more country to Peter's golf list. We played 9 holes at Elephant Hills Golf Club in Vic Falls. A unique experience and also testimony of how things have fallen apart in this stylish place. We were the only players at this course, which is located at a large resort which was entirely empty. The course was in kind of rough shape, punctuated by interesting wild life, including waterbuck ( a large antelope), lots of warthogs, impala. In any case, we had a fun time and added a little bit to the Zim economy, particularly to the appreciation of 2 caddies who were very happy to get some work.
Back to home base Gabarone today. We took a small 19 seater plane and got great views of the salt pans, part of the Kalahari Desert Reserve, a site of a future trip for sure.

Chobe Safari

On Friday morning, February 26, we flew to Kasane, a town in Northeastern Botswana, at the entrance of the Chobe National Park. We stayed in the Chobe Safari Lodge, a lovely facility on the Chobe River, just outside the park entrance. We had a room overlooking a Vervet monkey playground, and the lodge was an old African-style structure with raw wood beams, huge thatched roof, large common dining area, swimming pool, and waterfront for boat landings. On Friday, we did nothing but rest...we needed a vacation. Saturday had a game drive in the morning that was notable mostly for another Land Cruiser getting stuck in the mud (and almost tipped over;our guide was able to rescue the passengers of the other vehicle (there were lions around, and they had to get off the stuck truck) and escape the muck without disturbing the predators. A river cruise in the afternoon (lots of animals and birds, but the trip was on a large boat with several families of young children who were not controlled by their parents, and made for a cacophanous trip that scared the animals, bothered the adult passengers, and frustrated the guide, who gave up 1/2 way into the cruise.
The next day, we decided to do it right. We hired the same naturalist to take the two of us out privately, and we had a fabulous morning, seeing a huge variety of birds, and getting to study hippos, crocks, elephants, and the whole environment quietly and in detail. The afternoon game drive was similarly better than the day before, with great variety and much more detailed discussion by the guide. There were many huge herds of elephants, stately giraffes, mean-looking Cape Buffalo, and hoards of impala. The baby elephants were especially playful and loaded with pretend bravado. We watched wart-hogs cavorting in a waterhole...a mother and 3 playful piglets. Little did they or we realize what was ahead. At the end of the drive, we came upon a female lion and 3 cubs munching on one of the young wart-hogs (not for young audiences....ask us about the details under separate cover!)
We enjoyed the Chobe Safari Lodge, and thought the accomodations and food were excellent. It was a little large for our taste, which will affect our choices for future wilderness experiences.

Early End of the Week

We have had Internet access issues and have had to put the blog on hold. The week was eventful and stimulating. The best thing that happened was that Emily was hired by Thomas College in Waterville as their new political science professor!
Life went on here in Botswana, however. I was asked to consult on a patient with a huge pericardial effusion that prompted an echo-guided pericardiocentsis and resulted in >2L drainage. The next day, I encountered a man with a hemodynamically significant effusion (early tamponade) that also required an echo-guided tap and resulted in >200 ml drainage that relieved the tamponade symptoms and signs. Other findings this week were an ascending aortic aneurysm (nearly 6 cm) with AR, acute AR in a poor woman with underlying hypertensive heart disease, cryptococcal meningitis, AIDs, and TB (I think she had acute infective endocarditis), Ebstein’s anomaly of the tricuspid valve in a patient with severe ischemic cardiomyopathy, and a secundum ASD with RV enlargement and pulmonary htn.
Barbara’s birthday was today. She did some therapeutic shopping at the Botswana Cultural Center (a wall hanging for Duncan and an African story book for him also). We went out for dinner at the Gaborone Sun hotel, and had a very enjoyable meal, served in relaxed Botswana style.
We have been struggling with the Internet, and have had to delay contribution to the blog. Our Email access has been limited. Hopefully I’ll be able to convince the folks at the BUP office that fixing our internet access and ability to print are priorities.
Friday morning Barbara and I are traveling to Chobe, a game reserve in the northeast part of Botswana, where we'll be for 3 nights. We'll spend an additional night at Victoria Falls in Zimbabwe. This should be a great trip and both of us are ready for a break!

What did you do today?

Both of us were busy.Barbara prepared a talk to the Gaborone city clinics about TB law.She had been asked to speak by the medical director of the clinic based on problems with non-compliant TB patients and TB control laws in Gabarone. She found a rather blank group until she decided to switch to more practical information: she discussed a similar legal case in Maine with a non-compliant TB patient and the many problems with the adequacy of the laws this case uncovered. This account resonated with the group and created an interchange that kept the group engaged.
I was kept fully occupied at the hospital. I did an echo on a 14 year-old girl with a congenital heart disease who I recommended to undergo ASD repair. I tried to explain to the parents that a hospital that is experienced and that has high volumes of this type of surgery would be the best choice for closure. I encouraged them to go to Johannesburg despite the potential costs.
I also encountered a woman in her mid-fifties who had a 5.9 cm ascending aortic aneurysm with aortic regurgitation-- a perfect case for aortic repair and aortic valve resuspension. I hope the doctors here refer her to Johannesburg for surgery. I also found a patient with severe heart failure, likely due to hypertensive cardiomyopathy. The unique finding was that he also had sever tricuspid regurgitation likely related to a congenital problem, Ebstein's anomaly.
We are planning trips for the remainder of our stay. This week we are off for Chobe and Victoria Falls in Zimbabwe. We are also planning trips to the Okovanga Delta and Kalahari desert. At Easter, we'll do Cape Town and the wine district. Barbara told me there's golf at Victoria Falls, so be prepared for more details in this vital subject!

Not an exciting Monday

Morning report had exactly one cardiac patient, and the consult was quick and echo revealing. He had an ischemic cardiomyopathy with an apical mural thrombus and needed a cardiologist from US to recognize the problem and initiate appropriate therapy. I have a Penn med student with me for the next 2 days, and spent the off-time delivering extemporaneous lectures on heart failure and arrhythmias to him. I gave the 4pm Residents' lecture on heart-failure stages, pathophysiology,and guidelines for diagnosis and therapy, This subject was in part stimulated by the "grand rounds" delivered by a local cardiologist of questionable reputation who basically blew smoke and gave a polished, if somewhat inaccurate, review of drug therapy last week.
Barbara has been working on a review of TB statutes in the US to review with concerned persons at the Gaborone TB Clinic tomorrow. Her talk appears to be well prepared, but she needs to find out where exactly to deliver it!

Party Animals

We started today off with a long walk in our neighborhood, which includes many embassies and gated large homes of dignitaries, both foreign and domestic. It was a beautiful morning: sunny, warm, and summer-like. Later in the day we attended the jazz concert at the golf club. Today was special, as the Botswana motorcycle club was invited to attend. They arrived about 1/2 hour into the concert, spewing smoke with engines roaring. Here, as in our country, Harley is king. The typical burly bearded bare-armed denim vested look also is apparently required. The concert was fun and my colleague, Matt Dasco, a UPenn attending (from Houston) played tenor sax eloquently.
About 5pm we walked about 6 blocks to the home of Branco and Gordana Cavric (she is chief of medicine at PMH, unfortunately visiting family in Belgrade this week, and he is a UB professor of urban planning) for a Wildebeest and Oryx roast. Their friend from Serbia, staying with them, had hunted the animals in the Kalahari, and brought them back for stewing (along with ox-tail, pork, and goat). The stews were served with rice, peppers, and pop (maise prepared like dry cream-of-wheat), and actually were delicious. They had been stewing for 6 hours over a wood fire while the Yugoslavs (9 at my table alone) exercised their hepatic function with beer, wine, and other alcoholic consumables. We spent the evening re-fighting the Serbian war of the '90s, as we seem to do every time we sit down with a crowd of former Yugoslavs.
We also heard lots of stories about wild animals of the Kalahari and the Okovango Delta, which was fun and good preparation for our upcoming trips in late February and March.
I sat next to the Anglican Bishop of Botswana, who was asked to give the blessing before we ate. I was relieved they didn't ask me...the motsie might not have been well understood by the Yugoslavs. Barbara was at a table with all women, except an interracial couple, married in Moscow 40 years ago, who have found acceptance here in Botswana, where they have lived now for a long time.
Full of Wildebeest, we came back to our flat to prepare ourselves for the coming week.

Public Health Law Botswana Style

For those of you looking for something a little different in your BB diet, this one's for you. I have been spending time with a variety of players in the public health world here in Gabarone. Like all countries, how health policy and law is developed is a byzantine and mysterious process (especially if you are coming at it from the outside). This is a highly centralized system in which the Ministry of Health does a fair amount of micromanagement of the public hospitals for example (Princess Marina being the largest of this group). So many decisions that would in the US be made by some hospital VP or even some mid management person are kicked up and up the ladder to some Ministry of Health person. Last week I met with a senior management officer at the Ministry of Health who is in charge of "outsourcing", basically negotiating the contracts with many of the country's partners to build and service many of its health needs. Botswana is relatively affluent but has not yet had the opportunity to develop its human professional resources, so it needs to import much professional talent. On the other hand, there is a strong desire to put Motswana (Botswana natives) in all available positions. I understand from my contact that new public health acts are under development to modernize their system and look forward to seeing them when they become available.
In another venue I have been meeting with folks from an organization called BONELA (Botswana Network for Ethics Law and Advocacy). They advocate for the rights of HIV/AIDs patients in employment, access to health care, and housing, etc. They are a small NGO and I have agreed to help them with a position paper on a matter of great concern here. Botswana provides universal access to ARV (antiretroviral therapy) for HIV for all "citizens" of Botswana. So the many refugees to the country (many of whom are from Zimbabwe) and also prisoners who are non-Botswana have no access to these drugs. We are trying to come up with some good legal and policy arguments to persuade lawmakers to expand access to non-citizens.
I have also been meetingwith a UB law professor who teaches human rights law and is very interested in the development of research ethics guidelines and regulations - an important concern in countries in which a lot of foreign clinical HIV/AIDs research has streamed in.
Last night we had dinner with a new friend, a Fulbright fellow at UB from
California (USC). She teaches Alternative Dispute Resolution here - we discovered we had frieinds in common ( a frequent occurence in Gabs- crossroads of all nations!). At dinner we also met an American who works for a Belgian political consulting company charged with advising the Office of the President. Many interesting stories of this and former jobs, consulting during the troubles in Rwanda and Georgia.

The Week Draws to a Close

A young woman was referred by the private cardiologist in town with a large cardiac silhouette on chest Xray and an echocardiogram in his office revealing a pericardial effusion. He had considered that her problem might be due to TB pericarditis. I repeated the study on our own machine my eyes widened. She indeed had an effusion, but also had rather impressive hypertrophic cardiomyopathy. I examined her with one of the Penn students who was spending a few days with me, and the findings were classical! I hope to establish a series of TB pericarditis considering the numbers of patients with this problem I'm seeing. I tapped her pericardial effusion yesterday. The procedure was challenging, not because the access was difficult (I used the tried and true Mayo technique using echo guidance) but because all the lights in the room had burnt out, including the Xray viewbox. As a result, most of the procedure was done in relative darkness. I obtained my own minor tray from Central Supply. The lead technician there told me, "usually the nurses obtain sterile supplies from us, not the doctors." I told her that if I had to wait for the nurses, I couldn't count on when the procedure would happen. But the clincher was when I said, "if the nurses obtain the sterile equipment from you, you will need to depend on them to return it. If I obtain it, you know I will make sure it gets back to you promptly and in good condition!" She couldn't wait to get the tray into my hands.
The procedure went well, and we obtained plenty of fluid to smear and culture, and perform cytologic and biochemical testing on. The microbiology laboratory at Princess Marina Hospital is in a remote corner of the grounds, no signs for guidance, in a temporary building with the smallest of signs to identify the lab. Susan Lipsett, the med student who worked with me on this patient, poses in front of the lab "building" in the picture above.
The patient will be treated for her infection (likely TB). However, the fact that she also has hypertrophic cardiomyopathy will be an important factor in her future management and a survival issue.
Today, I didn't make it to morning report because of a critically ill 17 year-old primipara in pulmonary edema, who turned out to have chronic mitral regurgitation and required intubation and mechanical ventillation. She is in her 32nd week, and I think we can control her cardiac function without resorting to preemptive early delivery. Thereafter Grand Rounds was given by the same private cardiologist on "heart failure" that was quite a show. The talk appeared to be a protracted drug commercial. There was little emphasis on pathophysiology, the critical piece required by the housestaff to understand the basis of management and treatment.
A popular feature of the preceptorships I held at MMC over the years has been to take the residents to The Woodlands to play golf on my 1/2 day off. I have continued this tradition here. Matt Devers and I played at Gaborone GC (with caddies, no less) and had a beautiful afternoon. Our rental clubs were such that we had to share a driver, a "Big Brother" (Callaway knock off from China) that, despite all I have done to improve my swing, unrelentingly brought out my fade.
Tonight we had Shabbat dinner with the Ludmir family (Jack is doing a 2 week OB-GYN teaching position, while his son Jonah is a pediatric resident working at PMH). Jonah's wife Yael is an attorney volunteering at Bonella, a non-profit organization looking out for the downtrodden here in Botswana. Barbara will also be volunteering time with the organization.

Rain and Shine

The rainy season can produce prodigious thunderstorms and high-volume downpours. Yesterday evening, we went out for dinner at the local Chinese restaurant, "China Restaurant" at a nearby mini-mall. The restaurant had one other table of diners (a couple eating "Hot Pot" that began before our arrival and was still going strong when we left). There was a large group of maurauding 5 year-old children who treated the nearly empty dining room as their gym. Two secluded rooms on the side were set for dinner and when we left, we saw the large assembled Chinese family of the owners enjoying their meal.
The rain was pouring and the thunder and lightning powerful when we exited the restaurant. The parking lot was flooded with what appeared to be ankle-deep water. We swallowed hard and took steps into the deep puddle toward the car. Suddenly, Barbara was into water thigh-deep! She had inadvertantly stepped into either a giant pothole or a drain-pipe. Fortunately, the damage appeared to be limited to a mild foot-sprain, but the surprise, the mess, the wet, and the concern about worse injury made the entire event frightening. A warm bath, ibuprofen, neomycin ointment, icing, and sleep helped diffuse the potential injury a great deal, and Barbara is back to normal 24 hours later. We were glad we updated our tetanus vaccinations!
Today at the hospital was another productive experience. Among the cases I was asked to see was a 26 yr-old woman referred by a local "cardiologist" for a pericardial effusion, found on his echo exam. She indeed had a 4 cm effusion, likely due to TB, which I will tap tomorrow. However, he totally missed the fact that she had an enormous intraventricular septum with evidence of dynamic LV outflow obstruction, a condition called Hypertrophic Obstructive Cardiomyopathy. This is a major finding and will significantly affect our management strategies for her. Other studies ruled out myocardial scarring in a 60 year-old diabetic woman with an abnormal ECG, and helped forstall aortic valve replacement in South Africa in a 63 year-old man who had only moderate AS/AR and LV systolic dysfunction, who really needed appropriate medical care to reduce his symptoms. Yesterday I echoed the Foreign Minister, who will be happy to extend my greetings to Mrs. Clinton when he next sees her.
This evening, I had the pleasure of meeting Dr. Howard Moffat, the former medical director of Princess Marina Hospital, who shared tea and wanted to know my opinion about how to raise the level of subspecialty care in the country. We had a great discussion, but I suspect that the problems here are complex and have no simple answer.