Come on Mike, connect the damn dots!

As the discerning reader will recall I have ranted about health professionals and how they (we) don't ask the appropriate questions. To whit:

I was in a remote district hospital on Tuesday where I rounded on all the patients in the hospital, about 30. We saw a child of 8 years who was anemic to the tune of a blood concentration of less than 1/3 of usual. He had been admitted on several occasions "because he eats dirt", and had no platelets (the blood cells that promote clotting). I took one look at his blood count (called "full blood count" or "FBC") and had the diagnosis. His red cells were so small and so pale that they appeared like platelets on the automated count. He was so iron deficient that he had "pica" or "geophagia" and had the uncontrollable urge to eat dirt for its iron content. "So its not that this is abnormal. It is because he has no iron stores, is HIV+, and has a diet that is deficient in iron" I desperately wanted to add "you idiots!!!!" but there was that voice in my head again...We inquired about his diet which was awful as he came from a poor family and ate just twice a day, grain at that, no meat, and little green vegetables. We gave him some iron that was to be taken three times a day for three months, no just five days that had been prescribed on previous admissions.

On to the OPD where I functioned as the visiting surgeon, dermatologist, and family doc. I saw no less than three women who had abdominal paid that was characteristic of gastro-esophgitis (2) and lateral abdominal wall pain. As all had persisted in there complaints the MOs had obtained ultrasound scans on all of them. This happens way too frequently there as the MOs are fatigued and want to fish for a diagnosis that will satisfy their "customers" as the Ministry of Health has taken to calling patients. What garbage (the MoH not the MOs)....But I digress. All three now had become fixated on needing to have their gall bladder removed as it was the seat of all that ailed them. I tried and tried to explain that they in fact had "asymptomatic chloelithiasis" and that we had learned long ago that surgery had no place in this process and causes more complications than it fixes. All left unhappy...sigh.

Then a fascinating young woman. She was seeing me because she had a spectrum of complaints that made no pathophysiologic sense otherwise known as somatization. I have been trying to get the MOs to call this symptom complex "somatization" as it is more medically descriptive than as an example, "waist ache". As I sifted through the 4cm of her chart, there it was: "raped in 9/09". She was simply trying to reconstruct her life after a vicious attack that had completely destroyed her security. We made a plan to see her frequently and who cares about the complaint, just be with her.

Then my turn. It was a classic last patient of the day. The pilots were calling me to get to the strip so we could get back to Gabs before dark. My colleagues were in the truck waiting to go to the strip and in walks a woman with" stiffness" and "dizziness"....If I had a tebe for every one of the women (classically) that had had these same complaints... I did my best to take a good history, do a perfunctory physical, and explain that while I believed that she had a problem, it wasn't serious and that it should be resolved in two weeks. She was seen the day before and wasn't better so she came see the"specialist". A bit of a misnomer in my case, but be that as it may...I basically saw her fast and sent her on her way.

Now the OPD is constructed such that the docs can leave out the back door if they need a break or need to consult on another patient, a good thing. As I was leaving I had the chance to observe her walk from behind and noted that she had a wide based gait. I caught up to her and checked a few more things, noted that she had a coarse tremor (how the hell did I miss that?), added the fact that she had a very un-animated expression and there it was starring me in the face: Parkinsonism. This of course explained her stiffness and dizziness. We started her on the appropriate medication and she should improve within the week.

The dots Mike, connect the freakin' dots.

"Who owns your life?" Part two

The next day I was in a remote district hospital and as often happens I was asked by the nurse with whom I was working if I could consult on her case. "Sure"

It's a bit of a story but after an hour I still couldn't convince her that things were "OK". I finally found myself asking her if she believed me. She said yes...and then went off again as to how she was "still sick ngaka!" I ultimately wrote what I thought was the appropriate diagnosis in her hand carried chart,"card", she read it and lit up. What is "conversion disorder?" Ever so gently I told her how she must really be frightened about what she was experiencing and that there was no medical explanation for it. This is what it should be called so other MOs coming after me would better be able to care for her. The fight was on.

Try as I might to be a "target not worth shooting", it went nowhere. She was livid that I would "un-diagnose" her and was going to report me to the ministry. "Get in line", I thought, and played the only card I had left; that I needed to get to the airstrip to fly back. I dread going back next month.

Then yesterday I had the classic "last patient on a Friday" experience. I was asked to see a 25y/o with a common problem that had been appropriately diagnosed and was resistant to "treatment". Now the last doctor in line is always the smartest because all the hard work has already been done. I gave him an "atta boy" and that" this would resolve and good luck". And again things went south. It turned out that he had visited a local church that had invoked that he was bewitched (a common metaphor here) and that there was a "snake in my abdomen", also quite common. And extremely difficult to "treat" as it were.

I tried my best and then found myself running out of patience, said some unflattering things that will send me straight to hell on my demise, and, after an hour (!) opened the door to ask him to leave.

I whined to a Motswana colleague of mine and asked why this seems to be a recurring theme; wanting to believe one is sick even when a "specialist", a bit of a misnomer in my case, spends time and makes a more benign interpretation of the symptom complex. He rolled his eyes and said that that was just the way it is. I asked a medical staff meeting earlier that day if anyone had had similar encounters to the one in the remote hospital and it was met with peels of laughter, all had.

I just don't get it. And won't, I suspect.

"Who owns your life?"

Interesting how themes seem to manifest on a given week. I had noticed that the whole school work thing had lost the allure to the SOS kids. Oh sure they would get out their books and start alright but it was always short lived or met with that far off look of a kid that would rather be somewhere else. The house where I spend the most time has 12 kids, all guys, plus one three year old girl and another that is 16. Otherwise it is can be a high charged, don't give a bleep, emerging adolescent, testosterone filled junk heap. Sure Mma Caroline does her best to keep order but these guys have taken to tuning her out and head back outside to find more mischief. "They are so naughty!" she pleads as she chases after the three year old. Time for "The Papa."

By now I had a clear idea of what wasn't working; my mere presence, reading and helping with school work. True I would play and wrestle with them all during the summer (coming up) but they are now at risk of falling off the educational bus. 'Nuff's enough. One night last week a 12 y/o boy came into the house late for dinner, got dressed down by Mma Caroline, stood there and took it, then ran off to play some more football. Missing dinner was no problem, there were many girls that we only to happy to provide him some food. He's becoming a player, and now loves to rap with his pants on the floor and liberally use the N'word. I doubt he knows how loaded that is.

As he came in for a late (very) supper he was again admonished, ignored it, THEN FED, as this seemed to be the path of least resistance for Mma. Not for moi. I asked him to apologize and he gave me a look like I was from another planet. WRONG. We had a quick talk about respect and asking forgiveness and it went south. To his credit he is a good guy with a testosterone level that is on the rise and to which he hasn't become accustomed. So onto the hard counter went his skinny butt for a long needed "time out" until he apologized. I doubt that they get the minute-to minute, guy-to-guy feedback/mentoring they need

Now believe me I get that, absent coaching, this is unfair. So while he was immobile for a period, and thankfully fuming, I coached him about asking forgiveness and to simply say "I'm sorry"." Want to practice it?" Nothing, and the power struggle was on. I had to leave. I understand that it went nowhere and he went to bed without consequence. I have routinely seen this kid, one of the smartest I have ever experienced, be "beaten" by other house mothers as he adventures into manhood. They are fed up with him and they should be. So into his life steps a guy with a stronger will than his. Might not be a pretty sight....

This week I took him, his brother (13) and another kid (14) out into the middle of the football pitch (a bare field) under the stars. We sat in a circle and I asked, "Who owns your life?" The older two said "God.", although that might have been what they thought that that was the answer that I was after. The 12y/o in question said, "Me." Good stuff to work with.

"Why does He always forgive us?" "Why, no matter what, does He forgive us?" "Because he loves us!" the older two said. The younger was by now in a fat stew. "So why should we ever ask forgiveness if He always forgives?" "Uh, so we'll know?" "Yep and so you can grow to be men." The younger was on the hook and was being reeled in. "It's just that if we don't ask for forgiveness that we will eventually drive people who love us away from us" Even I was impressed with what was coming our my mouth. "All it takes is, "I'm sorry", then it's up to the other to forgive. But in the process you learn to change your behavior, to not hurt the other person."

So we practiced. We sat in the circle under the stars and said "I'm sorry" to the one on our left. I was sitting next to the 12y/o and when it was my turn he gave a curious look. "You're old. You shouldn't have to say that." "Oh, really? I live in the same live you do, not the same place. There are cost for my actions. Try it" Nothing..."Say it man, just say it", he was admonished by his brother. He spat out the words. Then we did it again, except this time I lightly smacked him on the leg. He jumped and I said I was so sorry that I had hurt him. Tearing up, he said "It's OK". OK now smack (the 14y/o) and say your sorry. "He might beat me" "Yes he might but he for sure will do it if your don't say you're sorry. Besides if he does I'll tickle him until he can't move." He love/hates to be tickled especially in front of girls.

Smack,"I'm sorry!" he said flinching. "No problem" and he turned to the 13y/o and did the same thing, stated he was sorry and around it went. After about five rounds and squeals of laughter others came over to join the fun. Soon the circle was about 10 and, as now there were girls there, things began to deteriorate from the male side of things. But as so often happens in life they would NOT let the guys getaway without saying those two words, all the while laughing at, what? Beats me.

It's the government! (version II)

As is my habit I often will pick up hitch hikers. They are innumerable. It gives me a chance to hone some Setswana, although I still am pathetic at it. As is my habit when Lynne is over in the US, I was venturing out into the bush over the weekend. Its quiet and I get a chance to sort out the cacophony. On the way back I stopped by a district hospital to round on a patient that I had seen the previous day. I was on the side of the road answering a call as a taxi was rolled by. All taxis are private vehicles with a small sign projecting from the window so I rarely recognize them. Out of the taxi I heard "Nnaka, nnaka are you going to Gabs?!" As I was in the middle of a conversation I tried to multi-task, ignored the entreaty, and continued with the phone.

I hate these bleeping mobile phones. There are people in my life that pay so much attention to the slightest beep or buzz that rudeness has left their sphere of awareness. Ah, dopamine. But I digress.

Next thing I know the person (a house keeper at the local hospital) hops into the car and makes herself at home. Ohhhkay, where are we going? She proceeded to fill me in about how she was headed to the north of the country to organize the funeral for "the sister of my mother's mother". Funerals are very important here to honor the family member.

On the way back to Gabs, I always pass a monstrous pothole that has been under repair for, oh, about 6 months. I always count the piles of dirt and rocks and there hasn't been been a change in the number. I truly count these, I know weird. So I asked my guest how in the world this could continue and she went OFF!

"These Batswana are lazy, all the tenders (contracts) are to the Chinese and no wonder, they get it done." Not very well mind you. "I just hate this! We are so lazy!" She went on about how she, a lowly housekeeper, was the mother of three kids and all were doing great. She had a house without electricity and still was able to make a living out of her station in life. "Why not anyone else?" And on it went. Turns out she was of the same tribe as the current president, His Excellency Lieutenant Colonel Ian Khama (this is a contraction of the true title, I swear). It is about one and a half hours back to Gabs and did I ever put nickel in her slot. She slowed down when we entered traffic and actually thanked me, asking God's blessing on me. I could really use it. I took her to the bus rank (station) and again she thanked me. New in my experience.

The child I discussed (alright bragged) about last post had gained 1kg as of Wednesday. Unfortunately I was squarely in the cross hairs of the mother as I went into my usual inquisition about the environment the child would return to. The house had nine people and no income. The child has a combination of protein calorie and mass calorie malnutrition, known as marasmus-kwashiorkor, so I was a touch (alright more than a touch) reluctant to send him back into the same environment. And while I should have anticipated this, it hit the veritable fan. The end result was the mom leaving in a stew and the grandmother coming into take her role. A good if not entirely satisfactory conclusion. The child will go home after a dietitian and social worker weigh in.

Progress is slow here and won't gain momentum until the Batswana truly take charge and control of their own medical destiny; absent the infusion, intrusion, insinuation, or invitation of the ex-pat community. Sounds remotely like another area of the world from which the US just extracted/abandoned. Owning your country is so nebulous and difficult; so many variables to consider. It can't be taught. Patience, unfortunately not a component of my being. Dammit.

Calories in should equal calories out

I was in a remote hospital this week where I had been seeing a malnourished child with HIV, Tb and a mother that was overwhelmed, didn't get it, ignorant.....something. I had been there a month ago and from then to my current visit he hadn't gained a gram! To be fair the weights are to the nearest 100gms but this guy was skin on skeleton. I sent a picture to the family so if you would like to see him send me and email or contact one of them.

Again that voice..chill! Even thorough this low watt, lamictal affected brain of mine I thought well this is either a case of the nurses not getting it as he hasn't really shown distress, other than he hadn't gained a flee-flappin', racka-frackin' gram and was too weak to kick up a fuss, or his mom just was not able to participate in his care. Each thought the other was at fault and the kid just stayed at 60% weight for height, severely malnourished, all the while the HIV and Tb were wracking what was left. They are the true hyenas of the infectious world.

How to get more calories into this little irritated chum and factor the adults out of it? Aha, says I. "Please get me a neonatal NG tube, a liter bag of saline ( a smaller bag would have been better but alas), and an adult administration set." Notice I didn't say get me the damn set! Good for me huh? I was after all still hearing that voice? " Now make up some of his formula but make it 1.5 the concentration." I did the calculations for this and out came a liter of formula.

I drained the saline from the bag, cut off a corner from the top and inserted the top half of a 20cc syringe, a funnel. Love me some Miny Leatherman Tool! Than, after assuring myself that the NG was in the stomach, poured the formula into the bag and hooked up the administration set (that clear tubing that leads from the bag to the iv) to the NG. It took a little futsing but by now I was in innovative heaven. Interestingly the NG tube revealed nothing in the stomach just an hour after he was supposed to have been fed. I gave a look of "really....Really!" and each of the parties pointed to the other.

Actually things came together rather nicely and in went the formula at a calculated drip rate to equal 200cal/kg/day. And what happened? The calculus as far as I can tell is this:

one irritated, starved kid (+)

one guaranteed source of warm calories =

same kid fast asleep.

I pointed out how we no longer needed to worry about who was going to give the food. We just needed to check the drip rate as we didn't want to over fill this guys microscopic stomach and give him aspiration pneumonia. They all agreed this was a good idea. Off I went to see referrals in the out patient department.

After I finished I went back to check on him and you can guess the rest of the story. To everyone's credit the NG was in place but the formula was off as the nurses didn't to "give him diabetes". "You mean fatten him up, get him sweet, why not?" We had a lengthy discussion about this during which I congratulated them about thinking about this but that even if he did get diabetes ( he couldn't) it was still OK to proceed. They agreed and one took the lead. We'll see next month.

His ward mate was also malnourished and was ready to be discharged but was on his mothers back so much that he couldn't sit at 19 mos. I sat him in a corner of his crib and his head draped forward. Everyone naturally went to his aid but I said to just wait and see what happened. One minute later he had great head control and was reaching out for some Plumpy Nut! I tried to get his mother to allow him to be a touch more independent but she would have none of it. She is San and desperately wanted to go home to the bush and be with her family. Fair enough, he'll develop there fine what with all the tactile stimulation he'll get but it would have been a touch safer to do it under some supervision. She had done her part in that he had gained 3kg in the last month and she wanted out. She lived with 8 other members of her family way out there. Would have been fun to go with her an see it.

Today I was at another hospital and saw the same situation, same malnourished child with HIV and Tb except this kid had lost weight in the last week. In went the NG, up went the bag, in went the formula, down he went. Cool.

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.