Sunday, November 30, 2008

Luggage-Notes on Zim and Vic Falls

"Where's your luggage?"
 
As it would happen, I arrived back to Johannesburg at the same time S&S were returning from Cape Town, which was fortunate because I couldn't figure out exactly where I had left my car in the airport, so I called them to meet up.
 
Oh, and I didn't have luggage. I was carrying a plastic laundry bag, from the Victoria Falls Hotel, which had my boxers, socks, running jacket, and running shorts. Those were the only possessions I decided to keep. The rest of my clothes, aside from what I was wearing, had been given away to mostly street kids in Zim. And my backpack as a gift to a friend.
 
I couldn't write when I got home from VF yesterday. There was just too much stuff to process. The beauty of the falls, the beauty of the land, the absolute friendliest people I've ever met, the desperate conditions under which people are living, the luxury of being in a grandiose hotel. I'll just present snippets here, in no order.
 
The Falls:
Spectacular, and it's not peak season for the river, which means were were seeing the falls at maybe half capacity. The deafening roar. The first view of the falls was the mist coming about the canopy of trees in the distance. Rainbows everywhere. We arrived on a day in which there were few tourists in the park (and there are way too few tourists period in the area). At times we'd be the only ones having a view to ourselves.
 
Currency:
The Zim currency is basically worthless. As most know, Zim has the highest inflation rate in the world, prices go up constantly. Thus, most things are priced in US dollars, and that's the preferred currency, with the Rand and Euro being used as well. Though, the conversion rate doesn't match exchange rates, so you do lots of negotiating for prices. For example if something is 10 US dollars, and you want to pay in SA Rand, the price should be 100 Rands, but often we found we'd be asked to 120 Rand and we'd have to negotiate back down to as close to the 10 rand as possible. I have included a pic of my 100 BILLION dollar bill. I'm rich.
 
The Banks:
Zimbabweans can only withdraw 500 Zim Dollars a day, a limit set by the government. Bank are closed on Sundays. 500 Zim Dollars will buy a tomato. A single tomato. One must go to the bank daily to get enough money for a loaf of bread. Obviously, people don't keep most their money in the banks. But one of the hotel workers was explaining how his money is directly deposited into the back, which makes it very trough for him and his family to survive. It's not good.
 
Shoes:
"I like your shoes"
Not a compliment. Rather a subtle line to ask if you're willing to part with them. Maybe trade the shoes for some souvenirs? What shoes are for sale (and we couldn't find many, even in the market) are far too expensive for most. On the final day, when Myr and I were walking through town distributing some clothes and food, we easily were met by at least 10 people who for days had been eyeing our shoes.
 
Bike Riding:
Saturday we rented bikes, and headed out into the surrounding areas, went along the Zambezi river, and ended up at this amazing Crocodile farm, which has 40,000 crocs, breed in captivity for food and skins, but also some re-introduced in years past (apparently there are now too many crocs along the Zambezi river). It was great. Got to hold a 2 year old croc. Observe a feeding. Lost a finger. Kidding.. It was great being back on a bike, and made me wonder how it is that I haven't had a bike since leaving Dublin. We were about 3Km from town when her bike chain broke, and it was actually hysterical and we just had to laugh at the situation. We had a HORRIBLE flight to Zim, which included a very tough landing (the pilots didn't come out of the plane) so we just had to assume that this was a continued string of problems with transport. We weren't able to fix the chain, so we rode back with her holding onto a rope tied to the back of my bike.
 
The People:
Fri night we walked into town to seek some dinner. Met a guy along the way who took us to a small house that served some food. We ate Pap (a maize-polenta) served with some chicken. The chicken on my place was a single drumstick, which had barely any meat on it. I suspect that this chicken was rather paltry when it was alive. The food was decent, the price was inflated, but pap is very filling. It's a staple, so not as nutritious as one would like, and given the cost of vegetables and meat, I suspect it's the major diet. Anyway, we ended up having a few beers in a local bar, and that's where we met Jackson. Decent guy. From there we went to a club which wasn't happening and so we went back to the hotel to sleep. The next night, we went back to the club, expecting to hear a band from Harare. We confirmed the time with Jackson and a few others, but of course when we arrived, there was nobody there, yet. We were sitting off in the corner, and were literally about to leave when Kvee (or Vincent) joined us. He's the main DJ of the club. We talked for almost 2 hours about conditions in Zim, and at the end of the 2 hours we had easily met 10 more people. I don't know how it happened, but we ended up leaving the club at after 4am. It was just so enjoyable to meet so many amazing people, dancing, drinking, having mini-discussions about life and politics. What I'm not explaining well is that these people really not only don't have much in the way of basic needs, but can't even get the goods. Kvee and I swapped shirts, check out the pics.
 
Healthcare: Home to Die 
We were trying to figure out what's going on in the area with healthcare. There is a public hospital. But it's basically closed. There may or may not be a doctor there. Which doesn't really matter since there are NO supplies. People don't even think about heading there. There is a local private doctor, but he charges something extraordinary for just a consult fee (something astronomical, maybe US$ 50), and if you get a script for meds, will they aren't available or affordable, so when I asked Ebert people do when they get sick, he said "we go home to die." Pretty bleak. Kvee has to take his 2 year old daughter to a sangoma (traditional healer) which is not what he would prefer to do, but feels compelled to do something when she is sick. Kids are no longer vaccinated.
 
The Grocery Store:
Myr and I went into the local Spar grocery store. Most the shelves were empty. There were some staples like cereal, biscuits, and bottles of water. The meat that was in the freezer looked very old. We were the only 2 people in there. And when we were in town, never really saw people going inside either, as most people were shopping at the market.
 
I have to wrap this up, have a lot to get done before leaving on Wed.. But I'm really bothered by what I saw. In contrast to the people of Soweto, the people in Zim were absolutely delightful, have just as little possessions, without the prospect of really getting more (and we're talking clothing, food stuffs here), but seem to keep struggling on. For comparison, mobile phones are everywhere amongst Sowetans, but I heard 1 mobile phone ring in the entire time we were there..
 
We were fortunate enough to be able to discuss politics with some people, and really most seemed to acknowledge that Mugabe must go.
 
 
How to Help:
We didn't have time to really put together a great plan...
I have a contact in Vic Falls who will distribute goods which are sent to him. The list is endless, but the practical things would be any clothing, (for any ages), shoes, pens (I was able to almost buy things with pens), paper, simple food stuffs, It doesn't have to be a big box, and more ideal would be smaller packages send distributed throughout the year. Luckily, packages are not opened by Zim authorities, and there is no import tax on goods. Please email me (javamania75@hotmail.com) if interested and I will email you the information and instructions.
 
Next post likely from Nepal.
 
 
BPB

Wednesday, November 26, 2008

An Open Letter, An Update, And Heading Off the Grid

Dear Blog Reader,
 
I wish you a Happy Thanksgiving.
 
I hope that you're able to celebrate with the company of friends and family. To me, Thanksgiving is the last pure holiday, and really the most important annual celebratory event (aside from my birthday, which hasn't been declared a national holiday, yet).  I was fortunate enough last year be able to celebrate with my immediate family in Colorado, and a few years ago to celebrate with my family in Chicago. In times past, I've also celebrated with coworkers, classmates, and occasionally random strangers (in Dennys). There is something wholesome about cooking a good meal and enjoying the company of those who are close to us, be they friends, family. But also taking a moment to remember what we're thankful for. Yes, the painful tradition of going around the table, verbalizing what we're thankful for...
 
The past 5 months have been quite eventful. I've had the great fortune to have been graciously given a leave from my residency program to come here to Jo'burg. I came here to learn aspects of medical care that I am not exposed to back in the US. In my short time here, I've certainly learned a lot of medicine, but it's been the other lessons learned which have been equally, it not more, rich.
 
I feel like I've learned about a human spirit or drive which I never knew existed, demonstrated by a population whom I get to care for every single day at work. This is a culture which, even in the midst of lacking essentials, seem to be thankful regularly for health, for family, for the care provided to them.
 
And that's something I'm learning, to be thankful regularly, be it for my health, my friends, my family (even if they voted Republican), my job. The idea of sitting around a nice meal with family and friends to celebrate what we're thankful for is very inviting, but perhaps it should happen more regularly than once a year? Perhaps if we spent more time thankful for what we have, we'd be less pre-occupied about the things we don't have.?.
 
I will admit that I am failing to live up to my Expat duties in spreading this event amongst my friends and family here in Jo'burg. I tip my hat to Randall who is hosting Thanksgiving in China, where Turkeys and canned pumpkin are non-existent, whereas both are in the store here in Jo'burg. (Ah, flashbacks to the first Thanksgiving in Dublin). I will celebrate Thanksgiving by having a nice quiet dinner with David, and maybe a few other. Sadly, S&S are out of town.
 
 
 
And for an update...
 
This is the conclusion of my Bara Pediatric Experience. I'm wrapping up with Cardiology, and headed to Vic Falls on Friday. It is pretty incredible to think about the children that I have taken care of the past 5 months. I remember so many faces and names. I have a special fondness for many of the kids, including the one child I wished would have been adopted, as well as a special recollection of the children whom I took care of who died these past months. I've learned about HIV/TB in kids, as well as how to manage the malnutritition states. I've become adept at drawing blood, starting IVs and other nasty, but necessary, procedures. I'm aware how my management style has changed, be it for better or worse, I'm not sure yet. I set out to accomplish a list of goals for my pediatric experience, and all of those goals have been met.
 
 
And heading off the grid...
 
I made a list of priorities for this year which didn't include medicine. One of those was to visit Vic Falls. And so I will depart on Friday to Vic falls and then return on Sunday. Many months ago when I booked this trip (along with Myrrith who is this amazing Dutch Ob/Gyn Resident who is friend of a mutual friend), I only considered visiting the Zimbabwe side; as it is the more impressive side to visit. This was to the objection of certain friends here who felt I should boycott Zim and see the Zambian side. Nevertheless, I didn't even consider it. Until Friday. When taking care of Baby T and hearing the awful stories that her mom and aunt relayed, I wondered how I could enter this country knowing that revenue from this trip will likely trickle into the evil bastard Mugabe's bank account. Of course, the competing emotion was to find a way to work in Zim for the next 6 months. So anyway, on Friday I'm off to Vic Falls... I'll make sure I get a blog post up as well as some photos before:
 
 
And further off the grid...
 
On December 3rd, I'm flying to Nepal. For a month. In a string of random coincidences, I booked a flight to Nepal for my December break. And then in September I made some arrangement to extend the trip for the whole month. I know there is a regular cadre of readers, and it's been motivating to know that people have keenly followed me on this experience. I don't anticipate regular blog postings, but am sure I'll pop into a net café and just drop a note to say hello.
 
 
One Last Note...
 
As for the upcoming holiday season, I'd like to make a plug for reducing material needs, and consider making a donation to a charity which will improve the quality of life of those less fortunate.  Consider one of these, or some other charity, be it local or global which addresses the health needs of the less fortunate.
 
 
 
 
Again, I wish you a fantastic Thanksgiving, may the turkey be moist, may the company be enjoyable, and may we truly remember that most of us have many things to be thankful for.
 
Cheers,
Brian
 
 

Paeds Synopsis

The other reg and I went to one of the wards this afternoon to do a cardiology consult. Our normal fashion has been to get as little information as possible from the referring reg, and just go see the kid, examine them, then look at the chest xray (if there is one) and the EKG (if there is one) and the labs, and come up with a diagnosis.
 
So today we went to evaluate S, a 5 year old. Part of the diagnosis was easy. He's a malnourished, sickly looking 5 year old. Who doesn't smile-at all. He had clubbing (the shape of the nail beds changes) and was anemic looking. He had swollen nodes, enlarged parotids, as well as oral thrush. He liver was 5 cm enlarged, and his spleen was sticking out by a cm. Not only was it evident that he was HIV positive, but also that his immune system was faltering. The only piece of the puzzle was which lung condition was causing the clubbing-was it TB or LIP?
 
Examining his cardiovascular system, which is what we were to focus on, was rather unimpressive. Slightly displaced apex indicating a generous heart size, slight parasternal heave (enlarged right ventricle), but normal auscultation. We examined the rest of the data. The EKG showed some a slight right axis, but more of an enlarged left ventricle, than the right we were expecting.. The CXR showed significant lung disease, likely TB, likely LIP. And the reason for the consult was cardiomegaly, based on the chest xray, which when reviewed carefully was not enlarged.
 
This boy is unwell. He's not on HIV treatment having missed his intake appointment at the pedi HIV clinic. He has had a partial work up for TB, but is not on treatment.
 
And it was clear to me exactly what needed to be done. He needs to be immediately started on steroids (for the impressive adenopathy surrounding his bronchi) and TB treatment (3 or 4 drug, it's debatable an abdominal ultrasounds to rule out TB in his abdominal cavity (which will change his treatment course for TB). What he really needs is to get on HIV treatment as soon as possible, which won't happen for 2 or more weeks (the time he needs to be on TB treatment before starting HIV treatment). There isn't an isolated cardiac issue. We'll do an echo tomorrow, but we'll have no recommendations for his care, other than to fix his medical issues.
 
And sitting there in ward 33, writing up his note, I realized that things had finally clicked. It no longer bothered me that I don't have "proof" that he has TB. I was no longer naive to think that maybe his malnourished state was because he didn't get enough to eat, but knew it was related to his HIV.
 
I have acquired a fund of knowledge which I didn't have before coming here 5 months ago. If (or rather, when) I find myself  being the sole pediatrician in an environment that is rife with malnutrition, TB, HIV, I'll know what to do, or at least where to start.
 
In the past five months I have not treated an asthma attack. I have not treated eczema. I have not treated "reflux" (which I am beginning to think is a diagnosis created by the pharmaceutical industry). I have not treated constipation. If I really thought about it, I'm sure I could come up with a list of 10 more "common" things that I have not seen here. Not to say that they don't exist, as common outpatient stuff is dealt with in the clinics..
 
In the past five months, I have written more prescriptions for ampicillin/amoxicillin, gentamycin, vitamins/iron/zinc (ps-every child with diarrhea back in America should also get zinc) than I have written in my 3 previous years. I have not written a SINGLE prescription for azithro, clindamycin, cimetidine...
 
What I'm realizing, is that I am developing two skill sets. One set of skills for the practice of medicine in resource rich environments (like back in the US), and one in resource poor environments And what I'm finding is a misconception about how my knowledge is changing... I don't expect to return to my program in the US being any "smarter" than when I left, and in fact, I suspect I'll be a bit rusty on things that I use to know off the top of my heard. I expect to return to the US, having a fund of knowledge which I won't use, and I already find myself dreading questions of "well, what would you have done in South Africa?"  It's apples and oranges. Different bugs, different drugs, different standards of care...
 
 

Tuesday, November 25, 2008

365,000 people killed in South Africa

Literally killed by a neglectful government...
 
"The new government is now trying to hasten the expansion of antiretroviral treatments. The task is urgent. South Africa today is home to 5.7 million people who are H.I.V.-positive — more than any other nation, almost one in five adults. More than 900 people a day die here as a result of AIDS, the United Nations estimates."
 

Sunday, November 23, 2008

So Much To Say

A lot has happened since I left for work Friday morning, and tonight (Sunday) I arrived home at just before 10pm, having been away all weekend. While I was driving home, the lyrics from "So Much to Say" popped into my head...
 
Friday Work: Baby T is a 7 month old male brought by his mom and Aunt who have trekked from Harare, Zimbabwe and have managed to make their way to Bara hoping, desperately to get medical care. He has a congenital heart defect, and was told the only hope for his survival was to get a heart operation, in SA. Inside the echo room, medicine was put on hold while, circles around Baby T, we listened to the absolutely nightmare conditions and quality of life that they experience in Zim. Forget what you might read in the papers or hear on the news (though there isn't much news coverage at this point given DRC, Obama, Economics), things are deplorable in Zim, and only hearing this first-hand account made it tangible how bad things are. The room was filled with a mixture of despair and anger. I ask you to please visit this web page (Thanks LR) and sign this petition: http://actnow-phr.org/campaign/zimbabwe?rk=XpeTF361rJatE
 
Friday Night: S&S generously hosted a going away party for a friend who works for the UN, and will be headed to Panama soon. It was a spectacular party, meeting great people from all over, but also being surrounded by many ex-pats from many countries. Having the chance to be surrounded by many people who have built their careers travelling away from home to help others is re-affirming.
 
Friday Late Night: The party winds down, with only a handful of us left, retiring to the patio couches and engaging in fairly deep conversation, as one would expect after that much wine.
 
Saturday, EARLY morning: S comments that the sun is coming up as he loads the dishwasher with the umpteenth load of wine glasses. The house is mostly put back together. I jokingly mention to the other S that our plan was to run Saturday morning, and he suggests we run, now. I say sure, thinking he'll cave, he doesn't. We decide to run before going to bed, and run for an hour and a half. Which isn't really recommended after drinking wine and eating all night. We see the sunrise of JHB.
 
Saturday, Brunch: S&S, myself, and the guest of honor from last night enjoy what will be the last meal together. It's a perfect afternoon (it was after 12noon), we sit outside for hours eating and discussing life, politics, travel, relationships, and gossiping.. When the second bottle of wine is gone, there is a group hesitation, realizing that the time has come to part ways, and wishing the guest of honor safe travels and continued journeys.
 
Sunday: I wake up expecting to have a cup of coffee and head home. After brunch I expect to head home. After an afternoon nap outside, I expect to head home. I end up at dinner with somebody from the party on Friday. I am finally on my way home.
 
And there is so much to say, so much to say, so much to say...
 
"So Much to Say"
Dave Matthews Band
 
I say my hell is the closet I'm stuck inside
Can't see the light
And my Heaven is a nice house in the sky
Got central heating, and I'm alright
Yeah, yeah, yeah
Can't see the light
Keep it locked up inside
Don't talk about it
T-t-talk about the weather

Yeah, yeah, yeah
Can't see the light
Open up my head and let me out, little baby
'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time

I say my hell is the closet I'm stuck inside
Can't see the light
And my Heaven is a nice house in the sky
Got central heating and I'm alright
'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time
Time, time, time, time, time, time

I find sometimes it's easy to be myself
Sometimes I find it's better to be somebody else

I see you young and soft, oh little baby
Little feet, little hands, little feet, little feet, little baby
One year of cryin' and the words creep up inside
Creep into your mind, yeah

So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say

'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time
Time, time, time, time, time, time

I find sometimes it's easy to be myself
Sometimes I find it's better to be somebody else

So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say

Open up my head and let me out, little baby

 

Thursday, November 20, 2008

F&F

[For HW]
 
The highlights of today do not relate to work (but work was great today).
 
Highlight #1:
I took the bakkie to the mechanic on Wed morning. Some new sounds emerged Saturday as I was driving back from my mini-weekend trip. Sounds which didn't sound great, but also didn't sound like the car was going to fall apart or spontaneously combust. I thought about ignoring the sounds for a few weeks, until it was more convenient to take the car in to the mechanic. I had the car in the shop 2 weeks ago for its 120,000 Km inspection, and it apparently got a clean bill of health, after getting a new ball bearing. So I was a bit annoyed that the clean bill of health only lasted 2 weeks, after costing me a pretty Rand (SA currency). Anyway, amusingly the mechanic is a local buy who has a shop right next to a gas (petrol) station. He wasn't at the shop on time, and I was afraid he wouldn't get there in time before my ride showed up to take me to work. The guys who pump gas said I should just leave the keys inside the shop, and head to work. Which, honestly, would likely have been fine. Not my usual MO, and a bit of leap of faith that the bakkie wouldn't disappear, but I knew full well the limits of my auto insurance for theft, and that had the bakkie gone missing, it wasn't going to be covered under my insurance for this. I imagined the conversation in my head, and hearing the agent say something to the effect of: "So, let me see if I have all the pertinent details. You left the keys to your vehicle with the petrol station attendant, and at this time the anti-theft system was disengaged so the mechanic could work on the car, but the mechanic wasn't there. And now your car is gone. Ah-hah. I see. The good news is we've decided you're a moron, the bad news is you're screwed. And we suggest next time just leaving a sign on the bakkie which says, TAKE ME."
 
So, they didn't get the car fixed in one day. I'm not even going to go into what was wrong with it, since they essentially had to replace the part that the dealer had to replace, plus fix the brakes.. The important issues was that I was sans car this morning. And not wanting to ask for another ride, decided I'd figure out how to get to the hospital on my own.
 
Options:
Bike. Don't have one, but that would have been ideal, perfect morning for a ride to work.
Walk. Doable, but a bit far.
Bus. Not possible.
Hitchhike. Totally doable.
Taxi. Doable, but a bit tricky.
 
So, I chose Taxi... Now, taxi isn't NY or Dublin stand on the road, hail down a car and get to work. Taxi is a 12 seater van, which usually drives a set route for a set price, which requires some complex hand signals to get the right taxi.. They are often very full. For a while the Taxis were death traps, as most were not road-worthy. Sometimes being held together by tape and string. But, there has been a campaign to get the road-unworthy ones off the street, and deaths from taxi accidents have declined. Literally. I called S because I had to get some of the basics on how to go about taking a taxi. He gave me an over-the-phone tutorial on how to get to work on the taxi.
 
So, this morning, I left ridiculously early. Was on the street corner, and as I saw approaching taxis I did my hand signal (finger pointing to the ground, with a wagging circular motion to indicate I needed a local taxi) and the third one stopped. I hopped in, and verified it was the local to Southgate (the mall where I would go to change taxis). As I mentioned a minute ago, most taxis are now road-worthy. This one wasn't. But it was early morning, and I didn't have far to go so I felt a bit invincible.
 
The taxi driver was kind enough to show me where to go to grab the next taxi to the hospital. I jumped out at a busy intersection, made my way to the next taxi, and was at the hospital in under 20 minutes! All for the cost of an equivalent  US$1.25. Not bad.

My coworkers were fairly impressed that I'd take the taxi to work. To be blunt: white people generally don't take taxis. And white tourists certainly don't take taxis. The joys of  being the outlier!
 
Highlight #2:
The folks at my favorite Jo'burg coffee house held a cupping tonight. Cupping is the coffee equivalent of wine tasting. It's a pretty systematic way of tasting coffee. I've been looking forward to it for WEEKS! And one of the attendings I'm working with is also a coffee addict, so I'd told him about it. My landlord and her family came along as well. It was fantastic. The guys really had the place set up well for the event. They had some local musicians playing, who apparently usually play next to the pay station at one of the local malls. The coffees weren't labeled, and identities were only revealed after the cupping was over. I must say, the Rwandan was superb, though the coffee is coming from the region that borders the DRC, and I guess the supply may be interrupted for a while. The Kenyan was as to be expected, and while I haven't been a fan of the Ethiopian it grew on me a bit. I've uploaded a few pics.
 
On a small aside, the new barista has spent a few winters working in CO, and is headed back for a week of skiing. Made me a bit jealous!
 
Well, the coffee buzz is finally wearing off...
 
Cheers
 

Sunday, November 16, 2008

Humble Applesauce

I bought some apples last week that were on-sale. They looked ok, but of course they turned out to be mushy within a few days. No big deal, it cost me the equivalent of a buck for a dozen of them.
 
So tonight I made applesauce with them. While waiting for the apple sauce to cool down, I decided to make my daily pilgrimage to the ATM. While the exchange rate is good, I try to go daily and am stockpiling money. It is perfect outside, a very cool breeze, and the sunset is spectacular.
 
As I walked to the ATM, I walked past a woman still selling her wares. Often containing sandwich bag size portions of snacks, but also pieces of candy and cigarettes. I see the kids in clinic with the bags of snacks, and also the kids walking to school often have a bag or two in their hands, but I've never really discovered what was in those bags.
 
So, walking back from the ATM, I asked for a bag, which cost a 1 Rand, and also got a bag of peanuts for 1 Rand as well. ZAR 1. So I gave her a 10 rand, and as she reached for change, told her I that was ok, to keep the 8 Rand. And the way her face lit up was tremendous. Thank you thank you thank you.
 
Humbling how the equivalent of 80 cents appears to have made this womans day.