Dueling with Snakes: A FAME Success Story

               The morning starts the way so many others have.  It’s pitch black and I am awakened to the sound of a phone ringing.  “Dr. Doug, we need your help.  There’s a baby seizing.”

               The hour is 4AM.  The experience is not an unfamiliar one; however, it has taken an odd flavor.  No longer am I speaking to a seasoned pediatrician with an arsenal of medications immediately at hand.  Conspicuously absent is the EEG technician who can tell me in real time exactly when a child is or is not having a seizure.  Instead, the interaction is parsed down to its most fundamental elements: a patient and her team of medical professionals facing the electrophysiologic demons fighting for possession of her soul.

The wazungu (white people) volunteer group at FAME.

               The mosquito net is thrown aside as I quickly find my way into scrubs.  The hospital is a 5 minute brisk walk down a pitch black dirt path, lit solely by my flashlight under the majestic canopy of the Milky Way.  As I walk, the treatment algorithms that I had memorized run through my head.  None of the medications that I would normally use at each step would be available.  It was time to rethink the algorithm, to step outside the comfortable world of child neurology to which I had been accustomed over the past few years.

               It is not long before the enemy is met.  It has taken the form of a 5 year old girl, whose brain, ravaged by fever, responded by seizing continuously for hours on end.   Her body, 1/6 the size of an adult, had already received more diazepam than an adult would before stopping breathing.  Despite this intense sedation, the child was awake, her eyes eerily open but unseeing, searching the right half of her world but seemingly never finding anything of interest.  Every ten seconds, she would call out; not the harsh scream of one in pain or the plainchant cry for her mother, but an otherworldly yelp more expected from the mouth of an animal than from a human child.  She kept her left arm flush tight against her body and her right extended outward, a pattern I had seen before: a figure-of-four pattern, one commonly seen when one side of the brain is furiously in the grips of ongoing seizure.

               The internal dialogue began.  There was no way to know for certain if the child was still seizing, but my instincts told me she was.  The mental algorithm at this point was clear: she needed a dose of a medication intravenously that was certain to stop her from breathing, but would stop her seizures.  Then I would be left with a child, unable to breathe on her own, and no machine available to breathe for her.  Instead, I chose an equally perilous path: to allow what might have been seizures to continue in order to keep her breathing.

               Perhaps in the real world, this would seem a common sense decision.  However, it flies in the face of the instincts that were developed in the American medical system over the years.  There, I am a brain specialist; my decisions are devoted purely to what is in the best interest of the nervous system, potentially at times at conflict of other bodily organs.  However, here, I am the child’s doctor: any potential risk introduced to the child will always be mine to bear, and any problem I create I must reliably and immediately solve.

               The algorithm broken, I work with the team to make a plan for the night.  Every complication is envisioned and an escape plan diagrammed, even down to choosing the size of the endotracheal tube should she stop breathing.  Medications are ordered and personally measured and delivered to the bedside, a process that ordinarily is simplified to the typing of an order.  The existential barriers of technology that came between myself and the diseases I fought came crashing down, and the experience became far more raw and personal than anything felt in an untainted academic environment.  Gone was the sterile smell of rubbing alcohol and latex, replaced by the smell of the evening campfire and urine.

               The fears of the evening staff were assuaged by 6AM, when I wandered back home; it would be closer to 8 before I had finished assuaging my own.  On the walk back to the hospital that morning, I walked past a dead black mamba, one I must have passed at least once in the dark just hours earlier.  The metaphorical significance of walking that close to death was lost to me, at least for the moment.

This is not the snake I saw that morning.
This is a cobra I saw while on safari in Lake Minyara.
Alarmingly, the snake in this story is deadlier than this cobra.

               The next day is quiet; her seizures calm, the fever abates.  However, she remains fixed in that same figure-of-four position, one that with the benefit of time I now recognize as a sign that one half of her brain is injured, but not actively seizing.  More curiously, she continues with those animal-like sounds as her face irregularly twists and contorts into lightning-like sardonic smiles.

               At this point, she is too complicated to be managed without the benefit of some aspects of modern technology.  The exam tells me there’s something wrong with her head, and to answer what’s wrong, she needs a spinal tap.  However, in a cruel catch-22, I need to know what’s wrong in her head before it’s safe to do a spinal tap.  This situation is easily remedied in the United States by any type of head imaging.  Unfortunately, this is not an available option, as her periodic need for oxygen makes her impossible to transport to a place able to image her head.

               It is at this point that this story takes a brief detour for a planned weekend Zanzibar getaway.  As this story is not about Zanzibar, I will woefully inadequately describe it in one paragraph.  Prior to going, it was described to me by a colleague as, “a magical place where everyone says hakuna matata.”  It is exactly that, and more.  Predominantly now a mixture of African and Arab peoples, Zanzibar was its own country for years until it was united with Tanganika in the 1960’s to form Tanzania.  In its storied history, it was colonized on-and-off by numerous colonial powers drawn to this tropical paradise: the Arabs, India, England, France, Portugal, Germany, and even traces of the Far East.  As a consequence, the island is a cultural hodgepodge of many peoples of Europe, Africa, and Asia.  Although predominantly Muslim, there are active Christian, Jewish, Hindu, and Jain communities.  The land is supportive of every kind of fruit and spice, including multiple fruits I had never tasted before (my favorite was the umbrella mango).  As a consequence, the streets smell sweet and savory.  The food combines all these elements: pineapple beef curry, roasted sesame roti bread, cinnamon pilau rice, cardamom in mashed potatoes.  Each night was spent by the pool, watching locals play on the beach as the sun set over the Indian Ocean.

I also got to have coconut water.
Unlike what they serve in the US, this doesn't taste like ass.

               Despite being in such a wondrous place (and during Eid, the equivalent of the Muslim Christmas), I was often glued to my phone, texting those still caring for this little girl.  She continued looking very unhealthy during my brief siesta, and more inexplicably continued to need oxygen. It made me wonder if the same disease that was causing her seizures was also causing her to stop breathing.  There is such a beast, known as NMDA receptor encephalitis, most recently popularized in the book Brain on Fire.  Unfortunately, there would be no way to test for this disease locally.

               Still obsessing over the problem, I remembered that a large number of girls with this disease have a growth on their ovaries.  So I considered that instead of testing for the disease itself, I could test for a fairly common cause of it.  It was a very circuitous way to test for the condition, but it was the only option available to me.  I ask a volunteer nurse practitioner to investigate her ovaries.  The text back: “It’s definitely abnormal.”

               The possibility of this being an autoimmune rather than an infectious disease was very exciting.  An infectious process would likely cause irreversible long-term damage to her brain.  However, NMDA receptor encephalitis has a large number of people making great recoveries (albeit after a very long time).  All we would have to do is remove the mass on her ovary.

This is not that little girl.  But I like to think
she will grow up one day and be this healthy.

               Rarely is one excited to return to work after finishing vacation, but such was the case here.  I went to see this little girl; she continued to look awful, without a drop of tone to her body and meaningless words spilling from her confused mind.  But now there was a new plan: don’t target the brain, target the ovary.

               Over the next several days, she made a remarkable recovery.  She was ravenously eating, and able to walk to and from the bathroom.  Two weeks after the start of her illness, I was preparing for her discharge.  First, her roommate was sent home.  As I finished giving her roommate’s discharge instructions, I could hear her voice over my shoulder: “My turn?”  Weeks ago, she was making animal noises, seemingly possessed.  Now, she was back to a normal 5 year old.

               She has since gone on to a larger facility to remove the ovarian mass.  I carry back to the United States with me a sample of her cerebrospinal fluid: the key to proving her disease.  In a few weeks’ time, we shall have a much better idea of her future.  But for right now, she is an extremely satisfying success story.

African Mornings

Remember the days when you didn’t need an alarm to wake up?  When you woke with the sun rise, and your body was so anxious to rid itself of sleep that it was insufferable to stay in bed?  The song in your head is not one you heard on the radio and can’t shed, rather it’s the background music of your life.  You knew that the day ahead was one to remember.  One where you will experience the payoff of weeks, months, or perhaps even years of planning and anticipation.  Possibly one in which you will meet challenges or opportunities you have never had before, ones you feel prepared to overcome, with meaningful experiences as your reward.

That’s what this morning was like.  That’s what nearly every morning has been like during my time in Africa.  At night, the darkness is absolute, an almost palpable heaviness to the air.  The lack of sensory input gently and slowly turns the brain off.  It is disarmingly relaxing, and I find myself in bed and asleep well before I had intended to rest.  Come morning, the energy of the world changes with the sun rise.  The light calls to action dozens of songbirds and crowing roosters.  You can nearly feel the world waking up, and the call is hard to deny.  Then you remember what you’re here to do, and it really is impossible to stay asleep.

This is my view while I eat breakfast.
I can literally see where my morning coffee was grown.

Breakfast is eaten outdoors on well-used sofas.  The view is of a sunrise, cresting over three consecutive ridges of mountains.  Directly in front of me opens up a field of tall grass that gives rise to a young forest.  Bizarre, foreign birdcalls surround me, and it seems as though all of nature is at play.  A bee encircles a small bird, who keeps hopping to and fro to escape his nagging buzz.  There are three wild cats nearby; two take turns jumping at insects that chance fly too low.  The third, the oldest, has slowly made her way to sleep at my feet.  The cats stop playing at the sight of a hawk flying directly overhead. It lands on the awning above me; its claws scrape loudly at the aluminum covering as it finds its footing.

I have gone to zoos before and have seen far less impressive displays of nature than this, a routine African morning.

The medical experience thus far dwarfs my time in Botswana.  Morning starts with 8:30AM rounds.  The facility has just 6 inpatient medical rooms, each with 2 beds.  Despite the low numbers, the acuity and complexity of patients is impressive.  Currently, over half of the admitted patients are children.  We spend a particularly long amount of time with one child who became neurologically devastated over the past three months; I come up with some answers, but without significant testing abilities, I’ll never know if I’m actually right.  The father, a proud warrior whose stretched earlobes and traditional garb could just as easily grace the cover of National Geographic, tears up at my explanation.  He will not be the last person to receive bad news today.

5 kids from a nearby orphanage, awaiting their turn
to see me.

The rest of the medical load, while significant, is African-casual paced.  Today, two orphanages delivered half their children to our doors, having heard that for the first time ever, a pediatrician has come to town.  I see five of them today.  The experience is exactly what I have come for.  These boys are largely castoffs, their motor impairments a fatal flaw in a society counting on them for manual labor.  Parents invest in children for the purpose of taking care of them when they're older; a disabled child is a poor investment.  So they are all withdrawn and forlorn appearing at first glance.  However, the way their faces light up at the sight of a five cent toy makes the thousands of dollars I paid to come here money very, very well spent.

The good news ends there, though.  For those two same boys, I can make a diagnosis: muscular dystrophy.  They will never walk again.

It is not all bad news, though.  A large percentage of families here do get the answers they've been seeking for a long time.  Down syndrome, Ohtahara syndrome; in these cases, I can offer a somewhat clear picture of the future, even if it is not the one they had hoped.  For others, they get confirmation of what they had suspected: that their severely weak, "disabled" child in fact has a full mind, capable of learning.

This is no small reward.  You see, schools here are very limited in their resources.  Any child with any somewhat significant problem is refused entry to school.  As an example, one 10 year-old boy was refused entrance to school his whole life because of a very subtle tremor, and they came to meet me to get a note saying he was medically cleared for school.  After TEN years!  In a more heartbreaking example, a boy with severely dystonic cerebral palsy, where he has basically lost control over all of his muscles (including his mouth and face), has a very full cognition, as far as I can tell.  When I asked his caretaker what I can help with, the boy replied, "I am a cripple."

Where schools have failed, the generosity of others have succeeded.  He was taken in by a Norwegian man, whose name I can't pronounce, let alone spell (it sounds like Skroli, but I'm sure there's an umlaut or two in there).  He has spent every cent he owns and has raised money from Norway to build an orphanage of sorts for children like him, children with significant physical handicaps but a lesser extent of cognitive impairment.  He takes them in and teaches them, not just basic schooling but also life skills, with the hopes of one day reintroducing them to their families.  So far, I have seen 7 of his sickest, and have given him half the money in my wallet to continue doing what he's doing.

Were it not for the FAME clinic here in Karatu and for Dr. Mike Rubenstein, the Penn neurologist who introduced me to the facility and is here with me now, none of these neurologically impaired children would have ever found the care they need.  Thanks to their charity, they are on appropriate medications now, and being cared for by people with the right mentality towards disability.

Skroli will have many more children for me in the coming days.  I hope I have the emotional wherewithal to handle them, and that I brought enough money to leave with a clear conscience.

My Own Personal Fight Club

It is 9:15 PM local time.  It is 2:15 PM back home.  My body has no idea what time it is or where it is; it just knows it wants to sleep.

I’m sure there are correct answers to this time/space conundrum.  The space answer is easy: I am at Addis Ababa International Airport, located in the capital of Ethiopia.  The time answer is disconcertingly relative.  Does local time even matter?  How often do I change my watch settings?  Should I put it at my destination’s time, as so many others have recommended?

I prefer to think pragmatically.  The time is 24 hours into my journey to Karatu, Tanzania.  24 hours ago I left my house with two bags weighing 50 lbs each.  Mercifully, those have (hopefully) made the journey independent of my efforts.  I have landed in Frankfurt, Germany; Jeddah, Saudi Arabia; and now Addis Ababa, Ethiopia.  I have watched a half dozen movies and taken probably a baker’s dozen naps, none more than 20 minutes.  I have seen the Arabian desert for the first time, even if only through a window of a plane.  I am typing through the last remaining charges on my electronic devices as I hunker down for quite probably the most painful travel hardship I have undertaken: a 14 hour layover in a very foreign land.

The airport is closing down for the evening.  Duty-free shops, tacky souvenir shops, and international cafés are shuttering their doors.  There are prayer rooms, separate for males and females, directly adjacent the smoking lounge.  There are a total of 8 gates at this central hub for much of East Africa, and probably an equal number of toilets.  (Side note: If I catch Ebola, it will be here.  The toilets are barely maintained, and no one was screened for Ebola upon entering.  I was forced out necessity to brush my teeth there, so if you see me in the news for having Ebola, please alert the CDC it was from Ethiopia)

Despite the late hour, the airport is alive.  Hundreds of people stream past, speaking dozens of languages, although English clearly predominates.  A group of men directly next to me are speaking in a language riddled with clicks and foreign consonant sounds.  There is a line of lounge chairs that people have staked out and are planning on sleeping on for the evening.  Clearly, I am not going to be alone in spending the night here.  I hope I find comfort and safety enough to catch another half dozen naps.

Reflecting on this moment, I am reminded of the movie Fight Club.  The movie, based on an existentialist, antiestablishment novel by Chuck Palahniuk, espouses self-destruction through violence as a means to break through the materialistic, manufactured life experience of millenials.  One of the many quotes that have stuck with me is, “It’s only after you’ve lost everything that you’re free to do anything.”  At this moment, I have no idea if my luggage will make it with me.  I have minimal access to food and water, and the overwhelming number of people around me threatens my innate sense of safety.

Yet despite these obstacles, the experience is liberating.  The lack of Internet means I have no idea what’s going on in the rest of the world, and quite frankly I don’t care.  The worry about publishing the paper I’m writing?  Gone.  The concern about figuring out what I’m going to do with the next 5 years of my life?  The new electronic toy I want to buy?  Even my ongoing struggle between atheism, agnosticism, and spirituality?  Well, it’s kinda hard to care about such things when life gives you more immediate concerns.  Traveling is my Fight Club.

I make it sound as though I feel threatened or in any sense of a panic.  It’s actually quite the opposite.  This is not an adrenaline rush type of satisfaction; rather an acknowledgement that I can no longer take the simple things for granted.  The experience is quite disarming.  There are dozens of travelers asleep nearby, with their possessions laying at their feet.  Others will leave their luggage behind to lay claim to their lounge chair as they go stretch their legs.  In other words, their possessions lay unprotected on lounge chairs in a busy airport with hundreds of people streaming by.  There is an unspoken amount of trust between these people, people who are very unlikely to speak the same language as the others here.  In America, inability to speak English is a tremendous barrier to trust.  Here, it is a fact of everyday life.

A lounge chair has opened.  It has been over an hour before I could find an opportunity like this, and one does not pass on an opportunity for comfortable sleep.  My flight departs in just over 12 hours.  2 hours after that, I will be in Tanzania.  Assuming no issues with a customs intake process where I’ll be bringing 50 lbs of medical supplies into the country, I will (hopefully) have a driver waiting for me.  He will take me on a 3.5 hour car ride into the desert, where I hope I will find the Internet to post this.

It’s only after you’ve lost everything that you’re free to do anything.

In the Shadow of a Volcano

Writing is the only thing that, when I do it, I don't feel like I should be doing something else. - Gloria Steinem

 Ah, it is good to be blogging again, if for no other reason than it means I'm once again experiencing a new country, and a new world.  Today I write you from Ecuador, better known as the country closest to the Galapagos Islands.

This trip will be a unique experience.  Ordinarily, I pick a place, buy a flight, and have a general mental framework for what I want to do, but leave it very flexible.  I prefer to leave opportunity to meet strangers in a bar, then rent a car to go visit our bartender's hometown on a whim.  Prefer to need to meet locals to bring me to places where there are no taxicabs.  To learn enough of a local language to explain my destination (and to haggle their fee).  To discover hiking trails, archaeological sites, and restaurants by happenstance, not because they are well-known.

Rather, for once, I am putting someone else in the driver's seat.  For this trip, I discovered a comically cheap deal on a 9 day trip with a Philadelphia-based travel agency called Gate 1.  It was perfect; I am between trips and had already had to plan Botswana, and am in the process of doing the same for South Korea.  So I didn't have the mental energy or funds to do a larger-scale trip.  I honestly had no idea what we were even going to see until the day prior to departure.

Thus far, despite the cost, I am clearly living in more upscale accommodations than ever before.  I am currently writing from a lakeside resort in Otavalo, and you can see the water from my room.  They have porters that carry all of our things, and almost all meals and entrance fees are covered.  It's a tremendous difference from my usual travels, and I must say, I would definitely do this again in the future.

The demographic of our group is diverse, but skews a bit older thus.  I was nearly immediately befriended by a fiftysomething named James.  His first words to me were, "thank goodness there's another young person here."  In the hour we have spent together thus far, he has used both of the words "legend" and "prodigy" to describe himself.  He has mentioned he graduated a year early from dental school more than twice.  He has told me the maintenance cost on his beachside condo, and has mentioned multiple times that he has retired early.  James is unmarried, and spends most of his time traveling solo.  James was joined by Eric, a retired wall street executive.  He worked also worked hard with the intention of retiring as early as possible, and discovered he didn’t enjoy retirement as much as he expected.  They serve as reminders that I have truly a rare blessing to have a job I am in no rush to stop doing.

At the equator, there are no seasons.  As the earth spins through its axis, it rotates on its tilt, with the point that is closest to the sun alternating on a sinusoid between the tropics of cancer and capricorn.  As such, the coldest it gets at the equator is when the northern or southern hemisphere is in its hottest part of summer (that is, when the sun is closest to the tropic of cancer or capricorn).  The closest thing Ecuador gets to a season is whether it is raining or not.  As an entertaining aside, depending on the "season," the north- or south-facing windows of their homes may be variably facing the sun.

Quito is nestled 9,000 feet above sea level in a valley in the Andes mountains.  The city stretches for miles in a north-south direction, but only a couple miles east-west, bordered by a mountain on one side and a volcano on the other.  The heart of the city lies in the deepest part of the valley, and most of the working class live in homes painted in bright pastels that climb the side of these mountains.  This is a theme recapitulated throughout South America and the Andes in particular.

Quito’s history, like most of South America, is framed by the Spanish and Catholicism.  It was first conquered by the Incas, based out of Macchu Pichu in neighboring Peru, who ruled through military might.  The local tribe resented their presence, so when the Spaniards arrived in the mid-1500’s, the Quito people offered their support to oust the Incans.  The result was a relatively peaceful transition, and consequently their historical district remains intact moreso than other Latin American countries.

Note: I did not take this picture. But it shows what
I was trying to describe.

The resultant vistas are spectacular.  In every direction there are homes jutting out of the clouds, framed by towering mountains.  Thanks to near-daily earthquakes, there is a limit to the height of buildings, and consequently the mountains often take the appearance of an arabesque mosaic.  There are no dominant buildings to the skyline, and each colorfully painted home adds its own tile to the larger work of art.  It is a distinctly different feel from American cities, where mankind’s desire to conquer and control nature results in a sprawling, gridlike metropolis that is limitless.  Here, humanity must comply with the limitations mother nature has set.  The steep slopes are not amenable to habitation.  The earthquakes command architectural respect.  And at all times, the active volcano Pichincha hovers above all, reminding us that in the end nature can have the final say.

Redefining the Standard

((Author's note: This narrative is meant to be read along with my photo album, which can be accessed via Facebook. Permanent link will come once I'm home.))

It is one of the most basic rules of traveling that the more places you see, the more places you want to see.  Never in my life have I taken a trip and come home satisfied, saying that now I can cross that one place off my list.  No, inevitably you talk to other travelers or locals and hear about places of amazing beauty or wonder.  Places that you otherwise wouldn’t have heard of when doing your research from home.  Inevitably, these places wind up being the more memorable experiences, and their uniqueness only further contributes to their mystique.

It is with this spirit that I made plans to visit Madikwe Game Preserve in South Africa.  Despite it being in a different country, it was actually dramatically closer than my other two weekend excursions.  It was a short one hour drive to the border, where obtaining (another) visa for both Botswana and South Africa was nearly the longest part of the journey.  Botswana is infamously less corrupt even than the United States; the cost of this fairness is in their expediency.

Immediately upon crossing the border, it was clear we were in a different world.  There were dozens of makeshift shanties constructed out of metal sheeting immediately adjacent to the road.  Street vendors aggressively attempted to sell food to quickly moving cars.  While my experience was limited to a brief stretch of road, the overt poverty was far in excess of what I had seen in Botswana, and this is despite the fact that South Africa has Africa’s strongest economy by GDP.  Of course, South Africa’s wealth is much more dramatically unequally distributed (albeit less unequally than the United States, but that’s a topic for another blog).

The nature of our environment was also dramatically different.  Monkeys randomly scurried across the road.  The vast flatness of Botswana was replaced by a far less level terrain.  There were more mountains, but not the mountain ranges typical of Appalachia or the towering Rockies of the west.  Rather, these were smaller-sized mountains punctuating vast expanses of relatively flat land.  It was clear that these were far older mountains; their size and rocky facade beaten down by millenia of powerful winds that flattened the landscape.

Entering Madikwe, we again encountered a group of desperate vendors.  Before long, we entered the preserve.  Madikwe is a luxury game preserve, where many of the larger game are flown in and kept to live in a large, enclosed area.  This enclosure is important, as South Africa has a particular problem with poachers (500 elephants were poached there last year, as compared to 1 in Botswana).  The result is a somewhat artificial experience, in that there is a far higher animal density than elsewhere in nature.  However, the manufactured nature of the experience is only slightly evident, and easily dwarfed by the overall ambiance.

For this experience, our group decided to forego the rustic, base experience of camping in the wild.  No, we found an extremely good price on a five-star hotel that exists within the preserve: Tunigi.  At this point, you should probably go to my Facebook album for the pictures that accompany this story.  Immediately upon entering the lodge, we were greeted by the owner, who gave each of us sparkling rose water.  We were greeted by an infinity pool overlooking a watering hole, where a herd of impala were at play.  We wandered the lodge to an outdoor bar constructed around an incredible tree, with surrounding tables and hearth.

Our rooms were even more spectacular.  Each group of four shared a cabin consisting of a spacious kitchen, dining room, and living room, complete with a porcupine-quill chandelier.  The ceilings were gigantic and the walls were mostly window.  There were two bedrooms, each with a fireplace, bathtub, and outdoor shower.  Best of all was a balcony with a view overlooking the park, where we immediately settled and enjoyed our complimentary Amarula.

The evening game drive was, to say the least, impressive.  Within 5 minutes of starting the drive, we see a zebra with some impala.  Pule, our guide, barely even slows down.  “Guys, we are not going to stop for just one zebra.”  We find a herd of wildebeest and some of the most colorful birds I’ve seen.  We find a whole family of zebra (adorably called a dazzle), going for a dip in a very muddy watering hole.  We see our first glimpse of elephant, the one animal for which Pule seems to have a fearful respect: “We will drive off-road to chase lions, cheetahs, leopards, whatever.  But we will not do it for elephants.  Too dangerous.”

Speaking of lions, we see two female lions out on a hunt.  Apparently lions are lazy hunters; they will pick a spot downwind of prey, and basically chill there, hoping an animal strays nearby.  This passive approach is why they are only successful on about 30% of hunts.  We stay long enough to realize that today was going to be a majority kinda day.  We proceed onward to the gem of the evening: a pair of wild dogs.  They are apparently quite rare, to the point that Pule actually took pictures of them himself.  Ordinarily wild dogs run in large packs, but the alpha male and alpha female are the only ones who mate.  We found the alphas alone, but unfortunately they did not put on a show for us.

Evening rolled in, so we stopped in the middle of the wilderness to enjoy some beers and revel in our photos.  Back at the lodge, our dinner was an amazing game meat: eland.  Dessert was a passionfruit panna cotta.  Everything was washed down by a sublime South African pinotage (I suppose that is redundant; pinotage is only found in South Africa).

The next morning, we get up early enough to catch the sunset.  A family of guinea fowl come out early to greet us on what proves to be the most epic (and I use that term lightly) game drive yet.  Nearly immediately we encounter a male rhino, marking his territory exactly how you think he would.  We continue a long way, and an elephant is spotted in the distance.  She is directly next to an extremely rudimentary road, and we talk Pule into driving up alongside her.  We stop the engine and marvel at the large beast, as gradually a baby comes into view.  Our hushed murmurs gradually get louder as two more babies join her, and we are wondering over a whole elephant family.

You'd be distracted too if this was right in front of you.

This proves to perhaps be only the fourth or fifth biggest highlight of the safari.  We continue back onto the road, and along the hills in the distance are a great number of elephants.  We can’t be sure of the number, but there are at least 10, one of which is clearly the biggest elephant we’d seen so far.  More impressively, though, we find two average-sized elephants on the road right next to us.  These two are casually eating, and gradually getting closer.  They wind up within 10 feet of our vehicle, all the while one of our safari members warning us that the big guy was getting closer.

After our friendly elephant, whom we shall call Dumbo, has sufficiently posed for us, we continue on our way.  However, we get approximately 50 feet down the road before we encounter the big guy, whom we shall call Stampy.  Stampy is clearly not happy.  He is approximately 20 feet tall, and easily towers over our safari truck.  He is walking aggressively up the road, in our direction, swinging his trunk and massive tusks back-and-forth.  “We must go now,” Pule says, and turns us around too quickly for me to get a picture, but slowly enough for the adrenaline to kick in.

As we proceed back up the way we came, the reason for Stampy’s less-than-sweet disposition becomes manifest.  No, he didn’t see a mouse; back up in the hills, we can clearly see two elephants in the process of creating a third.  The act is also over quicker than our cameras can capture, but immediately afterward, the successful male trumpets out a powerful bellow.  It starts low and rumbling, like a lion’s roar, and gradually evolves into the high-pitched blare that one traditionally associates with elephants.  It rattles your very being, in particular since this one’s message was, “leave me alone!  I’m fornicating!”  No wonder Stampy was in a bad mood; he was a spurned lover.

I know what you’re thinking.  By this point, you’d be counting this as a trip of a lifetime, and you could go home happy.  But not us.  Nay, we got greedy, and instead complained that we wanted to see a giraffe (well, more specifically we wanted to see a cheetah hunt a giraffe, but one takes what one can get).  Pule hears about one on the opposite side of the park, and so he quickly spins us around and tells us to hold on.  We are attacked by thorns and ruts as Pule drives down dirt paths that have no delusion of being roads.  After a while, we slow down, turn our heads and see this:

Immediately, we chastised Pule, as we had only requested to see a singular giraffe.

I call this one, "Hashtag no zoom."

Surprisingly, it is not easy to catch a glimpse of this herd of giraffe (appropriately termed a “tower”).  This is actually a bachelor herd, which is a group of males too small to reproduce.  We keep inching through the high brush, attempting to find an angle where we can see all of them clearly.  Then we hear from Pule that there is a dominant male straight ahead.

Sure enough, another giraffe that is at least 4 feet taller than any of the others is walking straight in our direction.  We keep taking pictures as he passes immediately in front of our safari truck.  The entire bachelor herd is now looking in his direction (and, consequently, our direction).  He casually passes directly in front of them and then beyond them.  We finally pass forward enough to see the whole herd, who start to put on a show.  Two of the males start to bump their necks together (“play fighting”).  All-in-all, way more than we expected.

On the ride back, we catch a few more memorable sights of kudu, impala, and hyenas.  They are our denouement, and pale in comparison to the rest of the day.  We return to a gourmet breakfast, and return to our rooms for one last outdoor shower.  We spend the early afternoon watching impala and wildebeest from our balcony, and come home completely relieved of our stress.

Experiencing Existentialism

It is 7:30AM.  The morning already feels odd, as there was no hot water for showering.  I am walking near the clinic, and as I approach there is a faint sound of singing in the air.  This has not been unusual; often our morning report becomes put on hold because nearby singing has become too loud to hear all the important medical details.  It was a presumption of mine that this was facilitated by a group of sisters who help run the hospital, and perhaps there was a choir being led nearby.

This morning, the truth was revealed.  As I walk past the open door to our common clinic area, I see the entire waiting room filled with people.  There have been no set appointments or appointment times; my patients are simply told to show up at clinic on a certain day.  On that day, they wait in the order in which they arrive, and may have a large number of patients not seen by the end of the day.  This is no small effort; I have had patients as far away as Francistown (approximately 6 hours by bus, and a not-insignificant cost to many of these people).  So naturally, people come early to ensure their effort is not in vain.

So here I was, an hour and a half before patients were to start being seen, and for many, their day has already spent waiting longer than any American waits for their physician (or waits for anything, for that matter, save the DMV).  They are not playing Angry Birds or Flappy Bird or any kind of bird on their iPhones, Galaxies, Notes, Nooks, Kindles, or Blackberries.  No, they will remain in this room with no form of entertainment except each other’s company, some of them for 6, 8 hours.

In this light, the singing is an almost expected result.  What astounds me is that there is a song that the majority of people in this room know very well.  I suppose that is a product of their homogeneity.  After all, what equivalent song would we have in the United States?  Don’t Stop Believing, America the Beautiful?  Perhaps the next time you’re waiting with a large number of people, try singing Bohemian Rhapsody, and see if anyone joins you.  See if it becomes a divisive maneuver or an act of galvanization.

For the Batswana, a far more collectivist than individualistic people, their singing proves unifying.  It is 9:30AM, and already there is no more sitting room for the day’s wait.  By noon, the room will be so filled with people that simply walking from check-in to an examination room will prove exceedingly challenging.  And despite the circumstances of waiting in a stiflingly hot room with hundreds of other people, the scene will remain calm all day.  This is as stark a contrast as can be imagined to the States, where an hour’s delay is cause to complain to a hospital’s CEO.

This willingness to endure hardship proves to be the theme of the day.  A mother fashions a carrying device out of a simple towel to secure her 3 year-old with limited control of their limbs.  I googled the cost of a Baby Bjorn, and this mother is coming out way, way ahead.  A teenager with kernicterus, whose muscles have become his rigid prison, to the point that they have sculpted his own bones into a corkscrew-shape.  His angel of a mother cares for him without the luxury of a g-tube; she still must feed him through a mouth he can barely control.  She physically carries a fully-grown person whose disease has robbed him of his ability to sit upright.

The day leaves an indelible mark.  A reminder of the great lengths that these people are going through every day to care for their children.  At the end of this trip, I will return to a life free from the burdens that these parents face.  A life not driven by the continuous need to keep up, to make it through each day’s struggle.  Most of these families will not get to act or live based on ambition, self-actualization or hedonism.  I suppose we should count ourselves lucky.

Because this blog was extremely depressing, here's
a shot of a family of giraffes I saw in Madikwe.
See?  Feeling better already.

Surviving the Kalahari

To project the impression that this trip has been all work and no play would be a lie.  The reality is, this experience puts together 10-15 people at a time, each of whom is a highly intelligent, ambitious, and often travel-accomplished individual.  These individuals also are coming from a world where they had absolutely no free time, and suddenly thrust into beautiful weather and more abundant leisure time; not to mention the fact that in a few years, the lot of them will have successful careers, but far less opportunity to enjoy their financial success.

The result is a nearly automatic new circle of friends.  One in which someone as socially challenged as myself, ordinarily too awkwardly nerdy to be brought into public, becomes merely above-average in terms of nerdiness.

This is the vehicle we took on safari.
I'm sure you're surprised it didn't start our second day.

Within 24 hours of arrival, we had successfully organized a group of 10 people who decided to go camping in the Kalahari desert.  Given any other circumstance, perhaps this would be a feat; however, it seemed nearly inevitable here.  We had hired a complete stranger to drive us 4 hours outside of the city and into the wild.  There were no instructions for preparation; simply to be ready for pick-up at 8AM.

This was my first journey outside of urban Gaborone and into the surrounding areas of Botswana.  Nearly immediately the differences were clear.  Donkeys, cows, and goats were very frequently seen on the side of the road, released from their pens to feed on the grass next to the road or in the median.  The landscape was unlike any others I’ve seen; the soil was replaced with a reddish sand, that gradually faded to the more traditional fine, tan sand one associates with a desert.  It was remarkably flat with only the rare hill or mesa jutting quite prominently into the skyline.

Random view out the side of the car.  Perfect sky.

We passed through multiple villages.  Most were predominantly consisting of small, one-room circular buildings with thatched, peaked roofs.  The people would be seen working the fields, herding animals, or gathered en masse for soccer games.  Whole families would ride on the back of a pick-up, driving full-speed down a highway.  Crops would be pulled in carriages pulled by 3 to 5 donkeys.  The locals would hawk their sweetroot and watermelons as we passed.  Most would stop and wave at our odd-appearing caravan, and we frankly felt like celebrities.  The weather was perfect.  The sky crystal clear.  The scenery was unforgettable.  And this was before we even arrived at our destination.

Boston Anna is also obsessed with capturing the million
butterflies in a photo.

After 4 hours in cramped quarters, we arrived at Khutse game preserve.  Immediately we are struck with the overwhelming diversity of life.  There were nothing short of hundreds of butterflies gathered outside the watering hole as we entered.  Dozens of buzzing flies produced a noise comparable to an entire swarming beehive.  There were at least two preying mantises, a stick bug, some kind of leaf bug, and something large enough to be a goliath beetle.  Most remarkably, for once I wasn’t the only person immensely impressed with the number, quality, and size of these insects.

Within minutes of entering the preserve, a family of ostriches obstructs the road.  They quickly flee across a widely expansive pan-turned-airfield.  We proceed to our campsite, and discover what our toilet and home will look like for the next 24 hours.  With remarkable ease, our tents are pitched, a makeshift sink is created, and lunch is served.  We eat quickly and go on our first game drive.

Home-sweet-home.

For the next 3 hours, we drive up and down dirt paths that are hardly bigger than the vehicle in which we traveled.  We see animals in their natural state, free to roam and interact with humans and with each other in whatever way they please.  We see oryx, hartebeest, springbok, ostriches, kudu, weaver birds, yellow-beaked hornbill, secretary birds, kory bustards, huge vultures and hawks.  A dozen Lion King and Jurassic Park references are made.  Sadly, as dusk falls, we do not see a single carnivore (except the birds, of course).

We settle for the evening, and nearly automatically everyone finds a role in preparing dinner.  A fire is made, and a surprisingly delicious spaghetti with a chicken & vegetable stir fry is thrown together (with wine, of course; we may be in the desert, but there’s no reason to be uncivilized).  Stories are told around the campfire under the most amazing night sky I am likely to ever see. This was one of the single biggest highlights of the trip; picture a planetarium with the brightness turned up to 11. There was actually a faint haze representing the arm of our Milky Way. This was the backdrop to a cacophony of exotic birds and animals. As we get ready to go to bed our guide, Leonard, warns us that we are not allowed out of our tents at night, even to pee.  After all, the lions, jackals, and hyenas come at night.

This photo almost does the night sky justice.  Almost.
Courtesy of Chen Yan.

Suffice to say, I was not eaten that night.  But the fellow travelers who slept less soundly than I reported hearing the cackling throughout the night of nearby jackals.  I suppose learning how to sleep through the ruckus of Philadelphia nightlife has its benefits; I was blissfully ignorant of the danger until the following morning.

We awoke before 6, hoping to catch the predators who hunt during the night and early dawn when it is far cooler.  Needless to say, the lot of us are not optimistic; then again, who is at that time of day?  When Leonard spends the next 10 minutes trying unsuccessfully to get out truck to start, we are rendered even further disappointed and eager to return to bed.  Ultimately the problem is found, and we are on our way.

We see the same animals all over again.  I’m not saying the same species; I mean the exact same animals all over again in the exact same place.  Most of us are falling asleep.  At one point, at a ludicrously far distance, we see a group of oryx.  As is a typical response to our presence, they start running away, but in an atypical direction.  While we pay no mind, Leonard stops the car, climbs out onto the hood, and scans the horizon.  “There is a lion,” he says matter-of-factly.

Now he has our attention.  All 10 of us throw ourselves to the side of the vehicle, trying to catch a glimpse of the beast.  One by one, we spot her.  She is a fully grown black-mane lion, a species found nowhere else in the world but the Kalahari desert.  She is stalking the tall grass about two football fields away.  We are all snapping away at her, and comparing whose distant faint blur actually clearly shows a lion.  More than once, we lose her in the tall brush.

I LOVE THIS PICTURE SO MUCH.

Fortunately, Leonard knows a secret.  Apparently tall, wet grass is a lion’s kryptonite (as David Jin noted, “They’re cats.  They hate water.”), and eventually she would come back to the road upon which we traveled.  After about 30 minutes of watching for her, we discover he is right.  The lioness is about 30-40 feet ahead of us, plodding along the road.  Once we spot her, she bolts back into the tall grass.  She stops about 20 feet away, sits, and turns her head right at us.  We have about 15 seconds staring down an unrestrained lioness within charging distance; none of us waste this once-in-a-lifetime photo opportunity.

A family of ostriches runs to escape death.

We continue a game of cat-and-mouse (pun intended) down the road as she attempts to escape us, and we hope to follow her to the rest of the pride.  We fail to find her, but do ultimately find a jackal.  We later make it back to camp and pack up, each of us abuzz about what we had seen.  As a friendly reminder of the unrestrained nature of the preserve, on our way out, a family of ostriches (one male, one female, and about 8 babies) obstructs our way.  Rather than run off the road, they continue to run forward until we separate the entire family.  It’s evolution, I suppose; hopefully their next babies will know to turn off the road.










Words can only do so much justice for this trip. It was a priceless, incomparable experience. It was filled with so much beauty, and so I leave you with a VERY small sample of photographs I took. I will eventually upload a full gallery on Facebook. Over time, as my travel compatriots do the same, I will link to their collections as well.

Blue clouds on a white sky.  Two vultures waiting on death.
Just another day in the desert.

The inimitable African sunset.

A Day's Work

It is 9AM.  I am walking down a shaded path between the buildings of Princess Marina Hospital, accompanied by one of the chiefs of the pediatric service.  It is at least 70 degrees and I have rolled up my sleeves to avoid sweating.  “Unfortunately, winter has come early this year,” she remarks to me.  I note that she is wearing a dress shirt with a light sweater over it, and get an acutely heightened sense of self-awareness.

That morning started the same as all others thus far: morning report.  We briefly review all the previous day’s admissions and discuss their management.  This is a familiar experience, although the inclusion of HIV status alongside age, gender, and chief complaint is unique.  With each case, the accompanying radiology films are passed through the crowd to be reviewed, as electronic radiology is unavailable.  I feel out-of-place attempting to position the light optimally behind the lung infiltrate.

This morning was unique.  The residents have had essentially one new neurologic patient per day, so my ability to contribute has always been there.  However, this morning was the first time they had a head CT to review.  The presenting resident commented on their frustration that the head CT was read as normal despite the child appearing quite ill, and was discussing the possibility of starting the several day-long process of getting this child an MRI.  Their head of pediatrics calls me to review the films, and miraculously I catch something that was missed: a subarachnoid hemorrhage.  I discuss in detail where it is, why it fits with the story, and how we can test for it without MRI.  Later, a spinal tap would confirm the diagnosis.

Up until that point, it was always on my mind that I was an outsider.  I come from a place that historically considers their people and their work as not only in a different continent, but in a different, “third” world.  Anything that could be perceived as arrogant likely would be, and that would be a wall that would likely undermine my whole purpose in coming.  So I held to silence until asked, finally, that day for help.  And, mercifully, it was one of the few times I could be of practical help.

In waiting, though, came significant appreciation.  Here I was not immediately needed to handle problems that would typically be out of the scope of practice of a more skilled internal medicine or pediatric physician.  Overall their comfort in navigating multiple anti-seizure drugs surpasses even some neurologists.  And for many of them, they are able to do so without having ever trained under a neurologist.  It is a humbling realization, particularly since these young doctors are doing their complex management without the infrastructure of pharmacists, computer checks, and insurance cross-checks.  Plus their world is one far more fraught with death and despair.

This lesson is one that proves particularly poignant in the management of the child I first mentioned.  After all, at home, I never manage subarachnoid hemorrhage.  They are typically handled by neurosurgery or neuro-ICU.  However, neither I nor these Batswana physicians have those resources available.  So it becomes incumbent upon me to take a lesson from them, and step up to the plate.

That is, of course, unless I get eaten by one of these
gigantic fricking spiders I pass everyday to work.

For today, I can take solace in a small victory.  Earning legitimacy is the first step to making change, and in the next few days, I am able to build on it.  It starts by being asked to demonstrate a neurologic exam.  It follows by being asked urgently to see someone they feel is very ill.  And hopefully it will finish with lasting change in the way they perceive and manage these neurologic patients.