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.

First Day

It is 1PM.  It is my first day, and after a full morning, I was dismissed for lunch.  Naturally, I eat quickly and come back in an hour; as it turns out, lunch is two hours here, so I find myself with a moment of time.  It is a brutal 90 degrees, and I am sitting outside the pediatric ward, which geographically is little more than 6 rooms, each room smaller than any given CHOP bed.  However, there is much to this space.  Each room is filled with up to 11 patients and their families, mostly spread across mattresses laid on the floor.  I saw 3 of them this morning, and each one makes it progressively clearer that I do not understand the world in which these people live.  Inexplicably, these differences make me feel far more responsible for and connected to these patients.

A child, no more than 4, is slowly sidling her way up to me.  She is being shy, looking away, but consistently making small steps in my direction.  Eventually she pulls herself up on the bench upon which I am seated, and she scoots up next to me.  She is staring at the computer screen, and periodically attempts to press a button.  She does not speak English, and my limited Setswana is apparently incomprehensible.  I wish I had a toy to give her; sadly, I did not think to bring any today.

Across the way from me is a boy who I believe to be her brother.  He looks to be around 2, although I cannot be sure.  His mother cradles him, and his clearly oversized head.  He has multiple vitiligo-appearing lesions along his scalp line, and the entire time I’ve seen him he has a right gaze preference and active right beating nystagmus.  He has yet to attempt any form of communication in the time I’ve sat here.  I quietly ponder how different his life could have been if they were born in America?  Perhaps no different.

The day has been filled with diverse pathology.  The medicine has been familiar but alien.  Every febrile seizure is complicated by a myriad of factors I don’t normally need to address: tuberculosis exposure, HIV status, kwashiorkor.  I feel painfully inept compared to my Batswana colleagues in dealing with these issues.  But we fortunately make a strong team, as they are always happy to offer their expertise and experience in sorting out important from less important details; ultimately, our plan makes sense.

Tonight, I will come home to discover the internet is out.  I will later learn that Spotify, Pandora, Hulu, Netflix, and Amazon Prime all do not work in this country.  I assume the same will be true for HBO Go.  On the plus side, I will also discover the value of (relatively) cheap, delicious South African wine, while enjoying a communal dinner with my fellow travelers.