Spacers

In the States, patients who use inhalers are supposed to use them with spacers (a chamber that you attach to the inhaler to ensure that the medicine gets to your lungs, not just the back of your throat). In Lesotho, they do not have commercially made spacers, but that doesn’t mean that their use isn’t important. So instead, patients have to make them out of water bottles or plastic cups. One day, I worked with a wonderful translator. Beyond interpreting, he would help me understand when my recommendations or suggestions were impossible in this setting with these resources (which was really helpful). He also made spacers, of his own volition, for each asthmatic that we treated. He understood the importance, and knew that these homemade ones probably didn’t last from one appointment to the next, so he took it upon himself to send kids home with one.

Heat

Our cottage, like all buildings in Lesotho it seems, does not have heat. However, at this high altitude, it gets quite cold at night (and inside cement buildings during the day). So, we rely on space heaters to help heat our toes.

Now, I’ve heard space heaters were dangerous, but I have very little first-hand experience with them. This morning I woke up to go to the bathroom around 6:15am, and I saw smoke in the hallway. I followed my nose, and walked into the living room to find our space heater in flames! As one of my roommates was packing to leave early this morning, she put her jumper on the back of the space heater and went to the bathroom, intending to speed up the drying process for only a couple minutes. Well, that was all it took. It must have been a funny sight to see three girls in their pajamas beating at a flaming space heater with a frying pan and a wet towel.
Needless to say, our cottage is now filled with smoke, despite all the windows being open and the fans on . . .

(Hmmm . . . What will Rafe say when he arrives today?)

Thaba Bosiu

Yesterday, I climbed Thaba Bosiu, a important historical site for the Kingdom of Lesotho. It is the site that King Moshoeshoe I (pronounced Mah-shway-shway) defended against multiple battles, and is buried at. It was really steep, but not that high, and I feel like I can't blame how out of breath I got on just the altitude : ) My quads sure hurt today.

Our "tour guide" insisted on shaking my hand over King Moshoeshoe's grave . . .



This is the mountain that the hats the Basotho wear is modeled after (so I hear).

ARG!

My computer hates me. It is currently paying me back for the hundreds of times that I have declined to update my computer with the software updates it offers me each time I turn it on.

I wanted to watch a movie tonight. I hiked up a steep mountain today, and I wanted to rest and relax on the couch. I had a hunch that I could rent a movie on iTunes, which it turns out was correct.

However, when I tried to rent the movie, my iTunes told me in order to rent and play it, I would have to update to the latest version of iTunes. So I said okay, and sat outside while the sun was setting with my slow, slow internet connection for the 30 minutes it took to download.

Then, when it was done and I restarted my computer, the iTunes told me I couldn’t access the iTunes store in this version without the newest version of Safari (which of course I didn’t have). So I had to download that, which took another 30 minutes.

Then, once Safari was downloaded and I went to put it on my hard drive to access it, I was informed by my stupid computer that I needed the newest Security Update in order to be allowed to use this new version of Safari. This download is currently in process (estimated at 40 minutes), my butt is numb, it is cold and dark, and once this is finished, who knows how long it will take to download the gosh-darn movie . . . ARG!

I’m beginning to get the impression a movie was not meant to be.

Hard Worker

Many people take their work home with them, but some people never stop working.

Empo is an HIV counselor. She is employed by Baylor for the Mokhotlong district. Each day, she comes with the Baylor doctor to the clinics and does counseling and testing. She is also in charge of all the testing done at the hospital, and sets up “Screening Days” to get more children tested in her area.

Most of the people in Mokhotlong use a horse or their own two feet to get from place to place, so when we were driving to the clinics we would give rides to some people along the way, in particular women carrying babies. When we picked them up, I noticed that Empo immediately would strike up a conversation with them in Sesotho, and find out if they had been tested, and if not she would encourage them to come to clinic to get tested right away. Some people would get really uncomfortable asking what could be interpreted as such personal questions of strangers. Empo, however, is doing a wonderful job in her country, with an HIV prevalence of greater than 25%, trying to get every baby that she can tested so they can get on medicines. For an HIV-infected mom not on treatment or prophylaxis, there is a 40% chance of her baby becoming HIV-infected. Of those babies, 40% of them will die before 12 months if they aren’t started on treatment. Those are sobering numbers, and Empo is doing an inspiring job in her fight against them.

Living Life

I am currently living about 8 minutes from South Africa. However, to get into South Africa I have get my passport stamped twice—in two different buildings with two different lines. The first stamp says that I am exiting Lesotho; the second stamp says that I am entering South Africa. This process repeats itself in reverse on the return trip back home to Maseru. I find this less than efficient.

But, a few kilometers across the border is a cute town called Ladybrand, with a lovely restaurant that is worth all the border-crossing hassle. It is called Living Life—and it is a delightful way to spend a weekend afternoon when living in Lesotho.

The restaurant has a farm associated with it, and they grow many of their fruits and vegetables on site. They also make their own soaps, preserves, compotes, bread, and amazing desserts (including the most delicious chocolate truffle with this dense fudge cake-like filling that makes my mouth water just writing this thought).

I cannot figure out what type of food they serve at Living Life. Various items on the menu include:

1. Pesto Chicken with Chickpeas and Pineapple Sandwich
2. Calzone filled with mushrooms, eggplant, olives, tomato, and feta
3. Scones with cream, jam, butter, and cheese
4. Pancakes (that are really crepes)
5. Potato rosti
6. Fresh raspberry juice

Basically, it is this wonderful schmorgasbord written on a chalkboard that doesn’t fit it any ethnicity or style. I love it.

The café has this wonderful outdoor eating area with fresh flowers on your table, fresh flowers all around in fact, and a “playground” with a trampoline, a rope swing, and area to play bocce ball, and swings. It just makes you want to relax and wile away the time.

This restaurant isn’t in guidebooks. You find it by knowing someone who knows about it who takes you there, and you thank them profusely for the favor.

Blankets

This is my kind of country. One of my most embarrassing secrets is that I have a baby blanket that I refuse to get rid of, and I sleep with it every night. I guess it’s not really a secret anymore, and I actually don’t think it’s that embarrassing, but Rafe sure does, and he HATES it.

In Lesotho, everyone has a blanket-- it’s a part of the culture and tradition here. Children get a blanket, and they wear them like capes. In the villages, I’d often see a child wearing his blanket like a superman cape and without skivvies on down below. Women wear the blankets around their waist before they have children, and above their waist after they become a mother. At this point in a woman’s life, the blanket becomes multifunctional. They provide warmth in the form of a poncho, and they replace strollers and are the main mode of transportation for babies and children. Moms simply swing their kid over their shoulder like a monkey, the child opens his legs in preparation, and then he gets wrapped in the blanket and snug tight to his mom’s back. I have seen many a crying baby get swung around and swaddled in tight and immediately stop crying once snug in their familiar position. It’s amazing.

A New Word

I learned a new word. When discussing family planning with one HIV+ mother we were seeing at clinic with her HIV+ child, she quickly responded, “Oh, Dr., don’t worry, I CONDOMIZE every time!”

QEII

I want to try to paint a picture. My intention is not to make everyone sad, although that’s likely unavoidable. My hope is to try to highlight just how different life is for a sick child in Lesotho than it is for a sick child in the States.

Piles of garbage lie outside the entrance to the Pediatric Ward of Queen Elizabeth II (QEII) Hospital, the main public hospital for the country. The garbage mostly consists of broken cots and desks and chairs, and it’s unclear how long it has been there, or if it just keeps growing and never gets smaller. The walls of the hallway are freshly painted yellow with multi-colored flowers, directing you to the Children’s Ward. While I can appreciate the attempt at optimism and cheer, the yellow looks more like baby poop and less like sunshine. I hear the crying and smell the dirty diapers before I set foot through the doorway. In the States, hospitals have a smell that people don’t like because of the association with sad memories, but the smell is more like antiseptic and less like sickness.

There is a bench at the entryway, where mothers and grandmothers sit holding their children. These are the babies who have been admitted to the hospital because they are too sick to go home, but there aren’t beds available, so they wait on the bench until a bed opens up. They sit there quietly, and they do not complain.

All of the hospital rooms, which just lead from one to the other like a maze, each hold 4-8 beds, which realistically means 8-16 patients because most beds are shared. Sitting next to the bedside of each child is a mother, or a grandmother, or an aunt, or a neighbor. A child isn’t admitted to the hospital if they don’t have someone to take care of them here. The moms provide most of the nursing care—they are an essential part of the hospital team.

Like the beds, patients who require oxygen often have to share an oxygen concentrator and split the nasal cannula. There are no ventilators here, so intubation isn’t an option. Chest X-rays are read by holding them up to a window or a light and giving it our best interpretation, not in darkened rooms with pristine computer screens and radiology-trained eyes. The medical chart is under the mattress or next to the bed of each patient. It consists of pieces of white paper bound together with string. IV fluids run at the rate that you try to adjust them to by estimating the speed of the droplets, not by a machine that can calculate it to 6.1 mL/hr, or whatever your heart desires.

Standing on rounds, I watched one of the many bugs on the wall crawl into an electric socket to hide out and listen. About a third to a half of the children are admitted for some combination of diarrhea, dehydration, and malnutrition. These children are lethargic, have sunken eyes, sunken fontanelles, increased skin turgor, and remind me of ghosts. There is a lot of variety of illness as well, including meningitis, heart defects, seizures, TB, pneumonia, and sepsis. In the States, by comparison, a more common problem is childhood obesity and the diabetes epidemic occurring in our children, and Asthma is one of our most common hospital admitting diagnoses.

I could write sad stories about babies who died in my short time there, about the crying and yet grateful mothers. I could describe the lack of supplies, and the lack of gauze and angiocaths and alcohol swabs and antibiotics, but I think this is enough for right now.

The picture of a hospital here-- it’s a little different than home.

The Hospital Store?

Next to the hospital in Mokhotlong, there is a canopied store. When we first drove by and I peered in, I saw shiny wood, and the other PAC doc with me thought there were guitar cases inside. We quickly realized that those wooden boxes were not meant to hold guitars, but were meant to hold people who didn’t make it out of the hospital. I have never before seen caskets sold in such proximity to a hospital, a place that I like to imagine heals more people than not.

I suppose this isn’t a crazy notion here. On the day we arrived in Mokhotlong, the hospital’s one blood chemistry machine (to get serum values of basic electrolytes and kidney function and liver function tests) and the CD4 machine (to help know when to start ART in an HIV+ patient, or to assess success of treatment) were both broken. The last time the CD4 machine broke, it wasn’t fixed for 4 months. Neither machine was working yet by the time that we had left, and I can’t imagine trying to take care of very sick patients without getting some idea of their serum electrolytes and organ function. There is a lot of limitation to not only treatment here, but also to diagnosis and management. I find it amazing that in a country who is doing amazing things for HIV treatment with ARV, no one in the region of Mohotklong currently can get a serum sodium level.

A Gentleman and a Cabbie

I was heading over to one of the PAC docs to have dinner on Saturday night, and I needed a bottle of wine or beer to bring. (My mom taught me always to have a hostess gift). However, I live on the outskirts of Maseru, and I can’t easily walk to a liquor store (or any store, really). I figured that I could have the cab stop, but I only knew of one store open past 3 pm on a Saturday, and it was pretty far out of the way.

So, when I got in, I asked if we could stop somewhere along the way, and that I knew of one place. He was silent for a moment, and replied, “Hmmm . . . let me think of a place that’s safe.” He was very concerned that any store still open would be unsafe for me. We started to drive, and I took a lesson from the Rafe Petty School of Taxi Etiquette, and we had quite a lovely chat. We stopped at a place that I will admit, looked pretty shady. As I got ready to hop out of the car, he got out as well. My cab driver insisted on escorting me into the store, stood directly next to me the entire time, and even carried my beer for me. He didn’t even get back into the cab until I was in the car and the door was closed.-- and all that for a flat fee cab ride, with no extra charge. He was such a gentleman.

Mokhotlong Photos

Don't judge me, I'm not a photographer. Nor is this by any means all inclusive. But, hopefully it give you a taste of the mountains and the villages and the beauty.

Should I call myself a City Girl?

I would not call Mokhotlong an urban oasis. It has one main thoroughfare that is, remarkably, paved. While there are plenty of cars, many of the people who live here use a horse as their main mode of transportation. It does house the district’s hospital, and it has two hotels with attached restaurants. Although, each restaurant serves basically the same five items off a pretend twenty-five item menu. Eating in the restaurant never took less than 1.5 hours, because I’m fairly certain there was only one stove-top in the kitchen.

I learned something from a self-proclaimed “city girl” from Mokhotlong, while driving to one clinic—driving into the mountains on roads not really meant for vehicles, while passing many villages and sheep and pigs and cows and people on horses and children without shoes or pants on. She told me that many of the people in these villages, if they made the trek to Mokhotlong, wouldn’t recognize a bus (this might be a slight exaggeration on her part). She refers to herself as a “city girl” on the basis that she can see the bus stop from her house. I can’t help but smile : )

My Home in Maseru

The Baylor Clinical Center of Excellence (COE), My "Cottage", and the Sunset view from the "Cottage"

TB vs. Swine Flu

You walk into a room and something smells like egg fart, but once you remain in the room for about 3 minutes, you don’t notice the smell much anymore. Ever had a similar experience? This is because we are able to adapt and create a new baseline of sorts. I’ve always thought that was an interesting, tangible phenomenon with that occurs with our sense of smell, and I think that concept can be applied to how we deal with all types of problems. Why else would we so commonly use the phrase, “Just give it time.” The more familiar we are with something, the longer since the initial insult, the less sad or scary the effect.

When I was in Mokhotlong, I met a saucy, chatty, and delightful woman. She works for the Ministry of Health and Social Welfare, and serves as a liaison between Baylor and the Lesotho government. She is very intelligent, and I really enjoyed her. However, when we were driving our longest drive to a clinic, she started to talk about how she was scared about getting Swine Flu. I responded—“Why are you scared of Swine Flu? I’m scared of getting TB?” She quickly replied, “I’m not scared of TB. If I get TB, I take some medicine and it goes away.”

This is the problem with our coping mechanism that allows us to adjust with time and familiarity. Tuberculosis is a serious, often deadly if untreated, infection that can cause disease anywhere from the lungs (most commonly) to the brain (with meningitis). It requires at least 6 months of a multi-drug regimen, and there are forms of Multi-Drug Resistant TB as well. It is far from a simple fix in pill format. Swine Flu (or H1N1), on the other hand, has turned out, currently at least, to not cause the fatalities feared like the Spanish Influenza, and instead is appearing much more like our typical seasonal flu. All our medications can really do is shorten the duration of illness by a day or two, and while it can certainly be serious for anyone, in particular the very young and very old, it more often than not resolves on its own in about a week.

But, in Lesotho, TB is commonplace, while Swine Flu is new and scary. To me, it would have been an obvious answer which disease I’d chose to contract. In this world, however, it’s not that simple.

Bactrim vs. Sweets

There is a tradition in Lesotho of children asking for sweets from foreigners. I don't know how it started, I don't know why it continues, but it is prevalent throughout the country.

I heard a story about the doctor who used to do his outreach work in Mohotklong. He used to get pestered constantly for sweets, so he started to offer bits of Bactrim instead of candy. (Bactrim is used for prophylaxis for PCP, a type of pneumonia that can be deadly for patients with HIV). It has a bitter, bad taste, and the area quickly learned not to ask him for sweets anymore.

I think if I were to live here for a year, I would bring boxes of toothbrushes and toothpaste from my mom (my favorite dental hygienist), and give that out instead : )

Super Nurse

At the clinic we went to today, I met superwoman. She is a nurse, and she staffs a clinic in a very remote area-- 2.5 hours on terrible roads from Mohotklong, which is already remote enough to be dubbed, "the loneliest place in africa." We went there today for the first time, to establish an HIV treatment program there.



In setting up a new clnic for Anti-Retroviral Therapy, there are a number of things that have to happen, including:



1. They have to be accreditied by the Ministry of Health.

2. The staff must learn how to appropriately test patients of all ages.

3. The staff must learn when to initiate ART.

4. The staff must learn how to initiate ART.

5. The staff must learn how to monitor and manage for side effects.



Each of these steps can take a long time. The nurse working in this clinic already knows how to appropriately test all patients, and has been referring them to the clinics that are closest for each patient. This in itself is a huge hurdle. she is so smart, and asks very intelligent and keen questions. When I told her that I had booklets of information for her about pediatric ART mangement, she was excited to read it and learn more and discuss it.



When a clinic becomes an ART site, it ends up being a lot more work for the nurses there. Tons more paperwork, tons more patients. While she is already tired and overworked, and she looked a little overwhelmed about the added workload, she herself said, "There are already so many defaulters in my community because the other clinics are too far away, especially for the patients that are already sick. If I can supply ART to them, it will be such a huge help."



Even though I could see how tired she was, and how lonely she is working there away from her family, her heart is so big that she is happy we are coming with our medicines and paperwork. What a role model. I need to remember her the next time I'm feeling tired, cranky, and overworked, and try to be just a little bit more like her.

Reasons this place doesn't seem real . . .

1. The farms are plowed by animals and men walking behind them with plows.
2. People here consider themselves "city" if they've seen a bus. (i.e. you are "country" if you couldn't recognize a bus)
3. Women balance 20 lb. bags of cow dung on their heads (which they will use to keep their houses warm).
4. Ventilated Pit Latrines
5. Houses without running water or electricity
6. Having to walk a day to get to a health clinic
7. Living far enough away from a doctor that you can easily die on your way to the hospital.
8. Horses, Donkeys, Cows, Sheep, and Goats . . . EVERYWHERE!
9. Delivering your baby at home-- because that's what your mother-in-law did, and that's what she wants you to do.
10. Shop signs that say "The Chemist."

Mokhotlong

I feel like I've traveled to a different world and time. The drive to Mokhotlong took us into the mountains-- and up, and down, and up, and down. I don't believe that we drove straight for more than twenty feet for the entire last three hours of the drive. And I'm sure the trek we drove (which is way worse during the winter months when the mountains get dumped on by snow), are a big part of the reason the town I'm in this week is dubbed by some, "The Loneliest Place in Africa."

From this town, we start out every morning going to the hospital-- which currently houses the only doctors for a 100,000 person district. The number of doctors also recently just dropped from 7 to 1, and as of today they are back up to three. We pick up any new lab results, see any difficult patients there, and then head out to one of the satellite clinics for "ART day". This is the one day a month that a Baylor doctor will be there to initiate patients on Anti-Retroviral Thearpy, or refill their meds, discuss HIV related problems, etc. Some patients travel up to a day to get to their clinic (even though the whole point is to set these up to make things more convenient, these patients just live in remote places in the mountains without cars).

Nurses staff these clinics on a daily basis, so we aren't there for general complaints. We are strictly there for HIV care, and to train the nurses so that the clinic can end up as a functioning ART center without any doctors coming on a regular basis.

It should be an interesting week. I already have plenty of stories to post.