Day 5: “It’s the government!”

It began at Ghanzi Primary Hospital where I rounded, mentored, and then at 1530 hit the road for the 7hr journey back to Gabs. About 2hrs into the drive, one where I was in a hurry as you do better in the light where the animals are easily seen and avoided, I encountered a vehicle half out into the road, stalled and obviously broken down. I pulled up and asked how things were. “Not fine, not OK”

I hopped out and quickly diagnosed the car with a metal shavings for a gear box. The six people that the car had been transporting were in the classic group, speaking and gesticulating loudly. I asked if anyone wanted a ride, no response.

As I started the car they all noticed I was leaving and ran to the rig demanding a ride. I stated that I could take three followed by more lengthy discussion. Again I started the car, discussion ceased, and in piled three Batswana, followed again with loud discussion, smiles and laughter. We exchanged names and what it was we did. The woman in the front was a maid, one of the men in the back was a teacher, the other a brick layer. And then it started.

“I wouldn’t need to ride if the government paid better” she said. This coming from a Motswana that could avail herself of a free or near free education up through university, free health care, underwritten costs for food, and more. She was joined by all the others. I must admit that my response was less than charitable.

“Tell me what your dream is in the next five years.” This was followed by a lot of “I wants” and laughter. It then occurred to me that laughter is so much a part of the culture that not only did it cement a relationship, deflect confrontation in a relationship, but it also deferred accountability. “How will you get from here to a “huge house and a good car”” I asked. Silence, followed by more sentences that contained “the government”. I asked “who owns your life?” Again silence, laughter, no response. "How many of you have children?" Two had a single child. "Really, how old?” Silence, neither the woman nor one of the guys could answer as they were both parents in abstentia. “Why are you leaving your child and going on “vacation” without him/here?” Silence. I had had it, and regrettably erupted.

“This is so emblematic of this country, of any country with an underclass. Who here has graduated from secondary school?” The woman hadn’t with any apparent reason other than ambivalence. “OK, that makes you both unfortunate and stupid. You’re telling me that you couldn’t walk to school for a free education? Was there a problem?” She teared up and I backed off, regretting my outburst of righteousness. The others were leaning forward in the seat and the gauntlet was thrown down. Everything was someone else’s fault and but for that they’re lives would be successful, right up through parenthood. I said to try not using the word “government” for the next five minutes. Silence again. I became even more paternal.

“Let me see if I get this right; you have free education, free health care, food at underwritten cost (that to be fair is stored dry as there often is no electricity for refrigeration), 160 days of paid time if laid off, and the like.”

Others have declared that this is beginning to resemble a “nanny state”. Maybe. The Scandinavians are close but why do they seem more successful? Are we in an adolescent period that necessitates this as a natural progression to due process and prosperity for all here? I admit it is easy to say when I come from relative privilege, but "why isn’t there any entrepreneurial drive?Who owns the grocery stores?” “The Indians.” “The dry goods stores?” “The Chinese and the Indians.” ‘The auto dealerships?” “The Indians”. The contractors?” “The Chinese”, and again to be fair the bids are low-balled courtesy of the Chinese government.“Why not the Batswana?”

All the stops were off and that voice in my head was ignored. “Why not build the bricks and sell them, not build with them, have an agency for maids, get a free PhD.?” Laughter.
“What is funny, why laugh?” “We love to laugh.” “I get that, but do you have an answer?” “All looked to the floor, a sign of humility here. Jeez I was righteous and was having no effect. Damn I’d blown it. But because of the venting I felt better. I know stupid, really stupid and not at all charitable. We sat in silence.

The only way things could have been more awkward was if the dark road was smokey from desert fires set by someone out there. We crept. Soon they were again talking and one translated. “We think you have a point, Rra.” “I don’t want to be right. I would like you to think and ask yourselves some important questions beginning with: If I’m here, headed on vacation, where is my child?” “Am I truly ready to parent?” “Exactly who is in my sexual network? These are easy and necessary questions with no easy answers and in a country with an HIV prevalence of 40% in your age group YOU need to be accountable to yourself and answer it”

As I write this I’m not proud of it but for the sake of transparency, something for which I dedicated this blog in the beginning, there it is. I got home with ambivalent feelings and then recalled how fortunate I was to have spent time in the remote bush.

Day 4: “Sure we like gays.”

I awakened early and hit the dust again. I stopped and saw the dawn eating an apple and some nuts that Lynn had provided and journeyed on. This was the day I had been looking to as it took me way out into the Kalahari. The Kalahari doesn’t’ stop at some arbitrary boundary. It covers the entire country except the delta and the ancient hills in the NE section. The vistas were stunning.

I rode across hard “pans”, dried shallow round lakes that are white after they dry. In the moon light one can read from the reflected light. Looking over each of the larger pans was a settlement; each village as unique as the next, each as quiet as the next; kids everywhere, playing football with whatever, squealing toddlers on the backs of mothers, incessant talking and conversation. At last I was truly in the land of the San and Batswana.

I have always felt that Gabs, and Bots in general, was “Africa light”. Now I was out in villages that at some level were still innocent and naïve, needing preservation not intrusion. I drove quietly, didn’t get out of the rig for fear of “contaminating” the village, and drove on. The 240km to Charles Hill was the most rutted I had seen. And when it wasn’t rutted it was “wash boarded”. Not sure which is worse, the side aches from being tossed around in the ruts or the headache from the wash board. On occasion the wash board was smoothed over with rock and sand. Interestingly the sand was akin to powered cement; limestone and chalk. Once wetted it was rock hard and unforgiving; talk about your headache.

I ultimately entered Ncojane, pronounced with a click, the kind where you use your tongue in the front of your mouth to make that “tisk-tisk” sound. I picked up three people and started to head for Charles Hill. Two of them quickly announced they were gay and was “that OK?” but with a bit of a confrontational tone. No problems here say I, and then encountered some of their friends before we got underway. These guys were true flamers, multiply pierced, in skin tight pants with a sway at the hips that belied the stereotype. I wondered aloud how this went down in a small village in Botswana. “No problem”, they said. I wish we so enlightened, PFLAG member that I have been.

We made it to Charles Hill on fumes and were chagrined to find out that there wasn’t any fuel in town. We asked around and were told to head to the border with Namibia where there was gas just on the other side of the border. Only trouble was that I didn’t have a passport. No worries the passengers said we’ll get an immigration person to do it. We went there and the guys negotiated with the passport clerks to have one of them take the rig over the border and have it filled with gas. I gave the keys to him, as if I had a choice, and some pula. 20min later he returned with the car and a full tank. Wow and whew.

We rolled into Ghanzi, 250km of paved road later, shook hands and parted. I got a room at a hotel I had used in the past and had a beer. Best beer I have had in country so far.

Day 3: Four wheel drive stress test

I have always wanted to drive the “road less traveled” north across the desert to Hukuntsi. One can travel east then north then west on paved or hard pan road to get to Hukuntsi from Tsabong or one can travel straight north over, well… I was about to find out. About 10km out of town I started to think that this would be cake as the road was hard pan and I was doing an easy 80km/hr. I had seen a jackal, some endangered vultures, and paw prints that had to be lion.

Then the paved road ended and the fun began; picture driving through flour, rutted and deep, for 180km. No use steering as the ruts take you where they will. I stopped frequently and wondered at the silence and again at the subtle but now more familiar changes in flora. There were gemsbok (pronounced “hemsbok”); huge elk sized animals that were everywhere. Also long needled porcupines, impalas, and more. I went through villages that had no real reason that I could see for being where they were, except that that’s where they had been for millennia. I stopped at all the medical outposts and introduced myself and began to “network” or at least left a bunch of B-UP cards. I always encouraged them to call the referral hospital, in this case Tsabong, for assistance but if for some reason they needed different help I was always there.

I got to Hukuntsi in about 8hrs, found fuel, and then called some physician friends that I have known since I came to Bots. It is so different to drive around when basically all I have done is fly in and fly out. I promptly was invited over to see them, and for dinner. Well I didn’t want to impose…”Dr. Mike this is Africa! You are always welcome and there will always be enough.” We ate “poppa”, a staple corn based congealed porridge, with tripe in a tomato sauce, and beans, and with our hands at that. It was the first meal I had had in three days and was fantastic. Beer was brought out and as I reached into my pocket for a multi-tool with opener the hosts just used their teeth. Africans that I have seen in several countries seem to have perfect and rock hard teeth.

I took pictures of all the families and insisted that they smile, something that isn’t normal in this culture when being photographed.

I slept that night on the grounds of the hospital, again marveling at the day and the stars.

Day 2: “Your coefficient of friction…”

I have always wanted to venture to the outposts where some of the patients I treat in Tsabong come from. There is an axis, if you will, of villages and outposts from Tsabong extending east to the main highway and west to the SW corner of Botswana; by the Botswana, South Africa, and Namibia junction. an area of hundreds of thousands of square kilometers. So out to the village of Middlepits I went at the posted speed limit of 120km/hr. Just outside the village I was nailed by a speed trap on the newly paved road. As the speed limit, or so I thought, was 120km/hr and I was travelling at 110km/hr I thought that I was OK. I pulled over and was advised I was going well over the limit of 80km/hr, posted just once, about 10km back.

“Uh what’s the problem?” “You are over the speed limit.” “What’s the limit?” “80” “Huh? Why, the village is still about 5km from here?” I was speaking to a police officer that was sitting in the shade of a tree at the bottom of a hill such that a car cresting the hill would be nailed without the first hint of the presence of cops. Low hanging fruit if you’re a cop. “Why 80?” “Because the coefficient of friction on the road is too high at 120 and the road will be eaten away!”

WTF??? “The co-effi…..WHAT!? What about the trucks that sped past me and are twenty times as heavy?” “We can’t stop them. They just go on by.” “Sigh….How much?” By now I was hearing that voice that surprisingly sounds like Lynne stating “just be nice”. Nice? Jeez I hate nice when I’m being shaken down. “P500”. I get the ticket and asked where I should pay. They say “at the nearest police station.” The ticket is now in various pieces all over the landscape.

I drove out to Bokspitts, at the aforementioned corner of Botswana, through a river valley of chalk escarpments and limestone cliffs; truly beautiful and at once amazing that Tsabong served such a distant population. Bokspitts and Middlepits are old Afrikaner settlements dating back to before Botswana was “Botswana”. The journey was extraordinary in that I slowly became aware of the subtle changes I was seeing in the surrounding landscape. “Magnificent desolation”, I think is how it has been coined.

That night I stayed at a local hotel in Tsabong staffed by a UB grad who was interested in the hotel management industry, a true entrepreneur in the making and one of the very few that have independent market driven business ideals here. I was the only one at the hotel and fell asleep to the sounds of the Soweto Gospel Choir.

Shh, do you here that?

That's right you don't, because out there, there is no background white noise; no 'beemers,' 'benzes, volvos, or range rovers that are driving too fast on too narrow roads with "performance exhausts". I am in the middle of the Kalahari, sleeping, away from the light and noise, and couldn't believe my good fortune.

I took off from home on Saturday and almost made it to Tsabong. As it was getting dark it came to me that I wasn't in a rush (or "damn hurry; rush-rush-rush" as Dad would put it) so I pulled over into the bush and camped in the vehicle that I had borrowed from Matt. Picture an SUV on steroids.

Off I went, found a place to settle about 500m from the road and then stood resting against the car for two hours as I watched the sun set. The colors went through the entire spectrum of white to yellow to crimson to blue to violet to black, all within a background of pure silence interrupted by the call of evening birds. I slept in the back of the rig with knees bent the whole night (too short a bed), and freezing (-8C) and loving it. Oh and the stars! The Milky Way was a gray streak occupying about 40 degrees of arc in the sky.

The next morning I stood again for about two hours as the previous night's spectacle was spun in reverse. I moved on to a village and waited for a small tuck shop (picture a 7-11 with a gas station Botswana version in the middle of the bush on a rutted dirt road) ) to open. There was a queue outside the shop with three cold cars and guys and lots of guy talk. The pumps didn't work "because they are cold". Apparently the pumps are keyed to magnetic switches that were indeed too cold to release the pump. So being the desperate white guy that I am I breathed on the switch plate and used my watch to reflect some light onto the plate to the laughter and glee of all the guys. They were gesticulating and laughing and in general having a great time at my expense in Setswana. That is until the switch freed up and the pump worked. Well...high fives all around and more laughter. I was able to get a tank of gas for how much I have no idea. Hey I was on fumes! Then off to Tsabong.

There is a new, and the village’s first, grocery store in town where I bought some water. While I was in the checkout line I noticed that the back ground music (I know, a touch weird in a village) was gospel as I heard the work "jeso", pronounced "jayso", Jesus. As I was pulling out pula to pay, the guy behind me started to sing along with a marvelously deep base voice. Soon the rest of the store; check out girls, stock guys, everyone, joined in four part harmony with clapping and stomping, free of inhibitions and worry about what others might think. In a grocery store!

"I might have been attacked by a lion"

OK, OK, take a collective breath already! It wasn't me. I do hippos, remember?

Last week I was in a hospital on the edge of the western frontier and was rounding with an MO there. He had an "orthopedic case" and did I think I "could handle it"? Well, "I could give it a shot.""He was attacked by a lion! And now he has a bone infection and two wounds that won't heal." "And what made the lion release his grasp?", say I. "Prayer", said the patient.

Now I'd be praying all right, but for a quick death. Lions aren't known to clutch, taste a well marbled (western fat guy) or sinewy (lean Botswana guy), and spit him back out. So out came Dr. Mike's version of the Spanish Inquisition.

"Did you see the lion?" "No, I heard it." "And you're sure it was a lion?" "Yes, well maybe".

Lions aren't completely gone from this area but the guy was herding cattle. Why him and not a non-praying cow? And what about the horse he rode in on? No, seriously, he was on a horse...If I'm a lion I'm going for the low hanging fruit, the ones who have, maybe, four neurons and two synapses on a good day. Oh, and they are bigger, dumber, and don't know how to pray that the predator drops his prey (loved that sentence). In any case I had that look of extreme cynical doubt on my face, that one I got from the teacher when I thought I'd premier the "my dog ate my homework!" shtick. "Really? Really???!!"

Turns out he "might have stuck it on a thorn bush". Now things were falling into place. I half way wanted to keep the charade of the bona-fide history going as I marveled at this guys imagination and quick thinking (well, praying) to get himself out of trouble. The wound didn't match the bite of a large cat (learned that stuff in my Medical Examiner days) but was part of a large deep scratch.

The guy thought he'd try one more time, "It was were the lion scratched me!" Sigh, this was getting passed humorous and into a bit of a pain, for both of us. So like any dim watt bulb I decided to treat what I could see, feel, or touch. The history was amusing if not wholly precise. It appeared that he had two discrete areas of erosion on the affected leg with huge lymph nodes in the groin. Given that the scratch made more sense and the wound was more consistent with that, and the the wounds were multiple and grossly swollen, and erosive (graphic enough for you?) I thought that this might be the second case of sporotrichosis I had seen, the other was in the same hospital. So lion story aside I made something up about how these particular lions were known to have these particular germs and that is why he got this injury. He thought for a moment, agreed, and told me that I should learn how to pray like him so God would also protect me.

He's right. I should.

Score: 1-1 Good Guys Win!.......well maybe

This has unfortunately become the same "song and dance" at several district hospitals wherein:

1. a desperately ill patient is presented at morning report with vital signs that are
2. incompatible with life or
3. indicate life is near an end or
4. well, you know the story by now.

So there I was at morning meeting and listening as a department head nurse reviewed the patients admitted from the last evening and those that might be of interest. She mentioned a woman "with HIV, in critical condition with PCP (now called PJP) pneumonia". She had an unrecordable temp and, well, the same song and dance. I know what doesn't work by now, and since that voice in my head was as loud as the last time, I thought I'd just saunter on over to the female ward and have a look.

By now of course her vitals were worse and she was gasping. Generally in these cases simple fatigue due to the stress of breathing leads to death as a patient is so sick that they have no calories to use on respiration . I asked her nurse if her IV was working. "Yes" And how did her O2 come off her face and why is she in the far bed with the curtains drawn so no one could keep her under observation? Cue the panicked look on face and shrug. So I calmly (no, really) went and asked the charge nurse and her charges if they could please come to discuss our patient.

We assembled around the bedside and I again inquired about the vital signs, IV, 02, general condition, and why she was alone, gasping and basically circling the drain. She was an all too familiar room as of the four beds there each has hosted an unnecessary (at least unattended, missed, or otherwise ignored) septic death. We were close to batting 1.000. As I reviewed the situation I asked if some one could get a new IV, some normal saline, another 02 line and something to warm her?

Inertia. Now it may be an overstatement that there isn't a notion of accountability in this culture but this situation spoke volumes to me. So I quietly did a slow white hot fizz, got some vicious heart burn, and gathered all the equipment myself and away we went. To their credit everyone started treat her. Not sure why it took so long but there you are.

She died 3hrs later. Score: Death and frustration-1, Patients-0

I went to male ward and found a nurse who could recite the pathophysiology of each disease process we encountered and knew her patients to the nearest decimal place. No one was going to destabilize on her watch without her knowledge of it. Her patients were just as sick yet they were in much better hands. Just like every place I have been, the culture of a particular ward can vary widely within an inpatient environment. In this case: Death-1, Patients-1. Tie goes to the home team. Good guys win. We'll take it.

Today Lynne and I went for a drive into the bush. I doubt most expats realize how near the bush is to Gabs. When I fly to outlying areas I can see it as close as a km from the airport. What I love about it is the quiet, the smiles, giving people on the road or trail a ride and taking them to their home. Many think this experience can only be had in the middle of nowhere and yet these people live and thrive so close to here. We wound around and saw some amazing homes, huts, cattle posts and giggling kids. The bush in winter is thinner and therefore easier to see through. The vistas will be only one of the amazing things I will always remember about Botswana.

"A febrile seizure".....

for no less than thirty minutes! (Insert frowning face with teeth clenched and hands to head in disbelief here). I felt like flopping and pulling a tantrum like the futbol players, but it wouldn't get me or the kid anywhere.

An MO at a district hospital asked me to review a patient on peds. He introduced him as a 6mo old boy who had had a "febrile seizure" but who hadn't "awakened". He apparently had a fever of (40.5C (>104F) and started to seize. I asked the mother how long he had seized and she said 15 minutes, then during the ride in the taxi for another 20minutes, then in the ED for another several before he got some anti-seizure meds. On exam he was somnolent and still stiff in his arms and legs. I wondered about cerebral palsy and asked about his birth--"fine", and how he was before he seized--"laughing and normal". OK, so I might not the brightest bulb in the chandelier but this ain't no "febrile seizure" as these are usually less than 5min and kids awaken without trouble. To be sure, it is a "seizure with fever" which is more deadly if unrecognized. I responded internally with...well, those that know me can fill in the blanks.

It occurred to me that he might still be in status so we gave him another hit of diazepam, just his second in TWELVE HOURS ( way too infrequently) and he softened into a deep sleep...with a stiff neck and an encephalopathic mental status. There were so many areas where this child had fallen through the cracks and where we had let him down that I couldn't begin to count. The MO was a touch chagrined and at my behest transfered him to a higher level of care to be CT'd and tapped. At least he was on antibiotics.

My left hemisphere desperately wanted to scream obscenities. But my right hemisphere, and this voice in my head that sounded remarkably like Lynne, held me back and instead I got a doozy of a headache. I got home, found the beer and, again, those that know me can fill in the blanks from there. This morning? Another headache but for a wholly different (and admittedly stupid) reason. More existential angst to chew on...... The good news is that "living color" are still there and thriving as they await adoption.

I went to Lobatse on Thursday this week , a national holiday and therefore quiet, to see a woman with a chronic condition. During our discussion I asked her about what it was like growing up in the area before paved roads, piped water, reliable schools and the like. What did she enjoy then, what was it like? She misted up and got a far away look in her eyes as she described a pastoral life that was as fun as it was dusty and muddy. Her parents were members of the ANC so they had to be careful of assassination by the Afrikaners from just over the border, 15km away. An amazing life.

We are in the dry season where everything is covered with a fine layer of dust. Interesting that the high end cars, of which there are more here per capita than any other place I have been, are all dust free. They are cleaned daily by the "help".

And to think that the people that have made it to 90 y/o have lived more that twice their life expectancy at birth. They have endured amazing hardship and don't view it that way at all. They have had a rich life and are rock hard. Incredible.