Botswana, Top Gear style
Last weekend we decided to reenact the Top Gear Botswana Special, so we borrowed a Toyota Corolla from the woman who owns Satellite Guest House, and off we drove in the direction of Nata. Our destination was the Makgadigadi salt pans, which during the dry season are basically just large, flat expanses of nothingness, but apparently when they flood in the wet season, they are home to amazing quantities and varieties of birds. Sadly its currently the dry season, and when we arrived at the Nata Bird Sanctuary we were told that we wouldn’t actually see any birds. Nevermind. We paid our park fee and spent a lovely afternoon drinking beers on the bird-watching towers, looking at animal tracks in the sand and enjoying driving our little borrowed car over the rough terrain. The pans look very dry, but only a few inches beneath the crust there is a water store, as we discovered when Will decided to off-road, and we got stuck in thick, gloopy mud. Luckily our car was pretty light, and pushing it out was no issue. We continued up to Nata and spent the night in the Maya Guest House, watching Miss Congeniatlity 2 on TV.
The next morning, we looked at our map over a breakfast of eggs and toast. It appeared that there was a main road running right through the middle of the pans; one of the few routes which we could possibly take with a non-4×4. We drove on to the village of Gweta, only to discover that this ‘main road’ was infact a tiny, sandy track. After asking for direction at the local police station, we were adivised to buy a shovel, incase the car got stuck. We drove to the hardware store, where the owner took pity on us, and although he had no shovels in stock, sold us his own personal shovel for only P30. We set off, only to find that the track was much worse than anticipated. The poor car was skidding and sliding all over the place in the sand, and finally we decided that enough was enough, and headed back to Gweta. We decided it would be polite to offer to return the shovel, and on returning to the hardware store, we found the owner waiting outside. “What? You thought you were going to drive on that road in THAT car?” he said. “Are you crazy?” he then proceeded to show us photos on his phone of lions which we had seen in the bush only a few Km from the village. We felt relieved that we had decided to turn back when we did! Next time, we will have to bring a 4×4.
Hi Five
The baby on the table in front of me smells faintly of vomit. As he draws raspy breaths through fluid filled lungs, I can see that his entire mouth is thick with thrush. I hold him still while the doctor first inserts a naso-gastric feeding tube, then attempts to put a cannula into one of his tiny veins. He barely moves or cries as the doctor inspects arms, feet, hands, wiping them with spirit, tapping them to try to find a vein. I don’t remember how many attempts were made before the cannula was inserted. I think I may have gone home by the time the doctor finally succeeded. The next morning I hear that this baby has died. The doctors are a little confused as to the exact cause of his death. He has pneumonia, bu had been responding to antibiotics, and thrush, though unpleasant, is not a killer. Basically, another baby dead from unknown causes related to HIV infection.
HIV has been a constant feature of our stay in Botswana. On our very first day, Dr Sinvula came to show us around the hospital. “In the beginning, there was a lot of stigma, and people didn’t really want to talk about it,” he told us, as we walked through the dedicated HIV unit next to the main hospital building. “But now it’s not a big deal.” Next he showed us the paediatric ward “a lot of HIV related problems,” and the male medical ward “this is mostly HIV related.” The virus is a huge problem in Botswana; one in three adults in Botswana is living with HIV, possibly the highest rate in the world. Fortunately, the country has the means to provide HAART to everyone with a CD4 count of less than 200, arguably the best antiretroviral program in Africa.
Despite the lack of stigma, it has taken me a while to realise that people are rarely referred to as HIV positive or negative. “RVI positive” (retroviral infection), “PMTCT positive” (prevention of mother to child transmission – used to indicate that a mother is positive), “PCR positive” (polymerase chain reaction – a test), “on HAART” (highly active antiretroviral therapy) and even “hi five” (HI V – geddit?) are all ways that doctors and nurses communicate the HIV statuses of their patients to each other. I have also got used to wearing gloves all the time; the majority of doctors won’t touch a patient without wearing gloves. Where in the UK we would wear gloves, in Botswana they would wear two pairs, and one pair would be sterile, as sterile gloves are thicker. Needle stick and splash injuries, and the associated HIV tests and post-exposure prophylactic drugs are just part of the job for health care workers.
I wonder what this part of the world would be like without AIDS. Botswana is a very new country, only gaining independence in 1966. Since then, it has gone from being one of the poorest countries in the world to one of the richest in Africa. Most people here do not consider Botswana a developing country at all; one of the doctors even tells me it has more resources that than the UK. What would Botswana be like today if it had not lost a huge chunk of its work force to AIDS? What would the country have done with the money that it now spends on antiretroviral drugs? 50% or so of the patients on the wards are there because of HIV; I try to imagine the paediatric ward with half the number of patients, no mattresses on the floor and no problems with understaffing. An advert on SABC urges young South African’s to imagine a generation that is free of HIV. Botswana has been a success story in treating HIV; I wonder if it also has the potential to be a leader in preventing new infections.
Good morning
I get woken up by the sound of a mosquito buzzing in my ear. Looking at the phone, I see that its 4.56; only 19 minutes til the alarm rings again. I lie back and sleep ’til the alarm wakes me. I hit ’snooze’ a couple of times before getting up for my shower, mug of cheerios, and the half hour stroll to the hospital. The real start of the morning though, is the morning meeting, which each department holds at 7.30. This starts off with a prayer, then a list of statistics from each of the wards belonging to the department. Admissions, discharges, deaths and numbers of HIV positive and negative patients are rolled off before individual cases are honed in on. Junior doctors then take over, giving details about the deaths from the medical notes, summarising the patient’s stay in hospital from start to finish. This over, the specialists jump in; “why was the patient given this antibiotic?” “the high temperature could have been caused by muscle spasms” “when is this anti-fungal indicated.” Once this grilling is finished, they move on to discussing other matters, before heading off to do the ward rounds.
Although long, and although I don’t always understand everything that is going on, I look forward to these meetings; this is where people voice their opinions and concerns about the healthcare system, and where I feel that I can really glimpse into the lives of the health care workers. Last week, two staff from an Infection Control board came round to give the obs and gynae department a briefing about swine flu. “There is no need to panic,” the infection control officer started off, before confirming that there had been several cases already at the hospital. “You only need to wear a face mask if you are seeing to a patient with flu symptoms. N95 masks cost 200 pula each (about 20 gbp) and we can’t afford to supply them to everyone.” This was met with protests from some of the nurses, who pointed out that they are often asked to cover medical wards, wherer there are plenty of patients with flu symptoms. Should they collect a mask and keep it handy for when they needed it? “No,” said the infection control officer, starting to look uncomfortable. “Surely the lives of healthcare workers are worth more than 200 pula,” said one of the doctors, “Some of us are HIV positive, on ARVs. We are concerned about infection.” Then the topic of Tamiflu. “We do have some Tamiflu,” the infection controller informed us “But I think it was a donation, and the entire stock expires next month. No idea when we will be able to get any more.” He went on to tell us that Tamiflu was to be reserved for confirmed cases. Samples from suspected cases would be sent to South Africa to be analysed; the process would take 10 days. “But surely after 10 days the patient would have either died or recovered.” The infection control officer looked even more uncomfortable. The talk was rounded off with the comment, “Don’t hold out for preventative vaccines. We know that the rich, developed countries are waiting to get their hands on these vaccines, and they have more money that us. We won’t get any.” The staff grumbled a little as they went back to work, but go back to work as usual they did. I wondered how British healthcare workers would have reacted had they received the same briefing.
“Botswana is not a poor country. We have no scarcity of money or resources,” was a comment from the hospital managment, relayed to us by one of the specialists, in response to complaints of understaffing. Every department has been calling out for more medical officers, but there simply don’t seem to be enough to go around. Those that there are, are expected to work very long, inconvienient hours. “Join your union” one of the senior doctors says in response to the medical officers’ complaints. In paediatrics, the lack of formula is discussed. Formula is given to babies of HIV positive mothers instead of breast milk, as part of the programme to prevent the tranmission of the virus from mother to child. However, there have been problems with the supply. The senior nurse tells us that this is because the company that is contracted by the Botswana goverment is also contracted by other african countries “They are greedy and take lots of contracts, and then they cannot meet the demand” she tells us. At least half of the children in the paediatric ward have HIV related conditions. Then there has been the “surfactant problem”. Surfactant is produced in the lungs of the foetus from about 32 weeks, and reduces surface tension, allowing the baby to breathe properly once it is born. Those babies born before 28 weeks do not produce sufficient surfactant, and therefore can’t breathe properly. Artificial surfactant can be given to them, but the supply had run out, and there were difficulties in getting more for various vague reasons. I asked the doctor how many of these babies, who should have been given surfactant, would survive. “More that 50% will die,” he said. I asked how many would survive if the surfactant was available. He reckoned that 80% would survive.
Sometimes there is good news though. Botswana has decided to provide ARVS free of charge to refugees living in camps. “We have to fight for every little thing, so when we get it we feel like dancing,” one of the specialists told me yesterday; the surfactant problem had been solved.
It’s a girl!
On the 6th August at 17.13, I delivered a little baby girl! I had just come back from a lunch break, after a morning spent in the ante-natal clinic palpating baby bumps big and small. Arriving back on the Labour and Delivery ward, we found two women there in labour, and the midwives assigned me and Eli one each. It was our third day in the hospital, and I’d seen a few deliveries, but I still wasn’t quite sure if I was ready to deliver one myself. I felt a moment of fear each time a babies head appeared – would the cord be round its neck? Would it start to breathe? Why were they always so blue? The midwives seemed confident that we could do it, however, and that’s why I found myself standing at the bedside of the young prima gravida, wearing a big heavy white gown and sterile gloves. On the other side of the bed stood the midwife, telling me what to do. Later, I realised that there were other people there; another midwife, Eli – even the obstetrician passed by – but during the birth I was so concentrated that I didn’t even notice!
Seeing the baby’s head at first, it looks like it’s being squashed. Putting my fingers in, I was worried about crushing the fragile little brain, but the midwife told me that I needed to check that the cervix was fully dilated; that the baby had a clear passage out. I was surprised that the head didn’t actually feel squashed at all with my hands around it. This woman had large hips, the midwife said, and there was plenty of room for the baby to come out.
“I think that you need to do an episiotomy,” said the midwife, “Take those scissors, put two fingers over the baby’s head, and wait for a contraction, then cut.” An episiotomy is a cut in the perineum, performed to allow more room for the baby to pass out of the vagina, and to prevent it tearing something more important, such as the anal sphincter. Before, when i had been waiting for the woman to deliver, I had privatley considered that if asked to do an episiotomy, I would stand aside and let the midwife take over. However, in the moment I didn’t have time to think. I grabbed the scissors, and when the baby pushed hard against my hand, I clamped the scissors shut. The mother moaned with pain. “Cut more, cut more” said the midwife, “Protect the baby’s head.” I tried again and again, but the scissors were blunt, and my episiotomy remained a dismal centimeter or so long.
“Hold the head,” as the next contraction came, the baby’s head slipped out easily into my hands, and I wiped it quickly with a cloth. Sliding my fingers round the neck, I was greatly relieved not to feel a cord there! All at once, it seemed, the grayish baby was out, and I clamped and cut the cord, wiped the baby and dangled it above the mother, for her to see that it was a little girl. There were injections to administer to mother and baby, and my hands shook like a leaf as I stuck the needles in. Gently, the placenta was teased out, and it was all over! I declined to suture the episiotomy tear, deciding that I had put this woman through enough pain already. Instead I watched as the midwife injected lignocaine, and began painstakingly to look for tears (there was one fairly large one, due to my poor episiotomy, but there wasn’t much blood loss, which was a relief.)
This woman was brave. Though she winced a little as the midwife began to suture, she busied herself with fielding large numbers of calls on her mobile. She seemed so happy! “This is a strong lady” siad the midwife. Indeed, all the ladies who I saw on the labour and delivery ward seemed to me to be very brave. The vast majority gave birth with no pain relief, with pethidine being given only to those in severe pain. Epidurals, which are now so common in the UK, just cannot be offered to all those delivering vaginally, spinal anaesthetics being reserved for those requiring caesarean sections. It did make me a Eli ponder how different the attitudes to childbirth seem to be here and in the UK.
Later, as I looked into the little cot, where the baby was bundled up in blankets, only her tiny face visible, I felt a little lump in my throat. I was very relieved that the delivery had gone smoothly, and that baby and mother were safe. I carried the little bundle back into the ward, where the mother was sitting up in bed eating porridge. The nurse brought in another cot, and I left mother and baby together. The next time I came in, the mother had moved the baby into her bed, and was breatfeeding it; the first mother who I had seen do so on the ward. I thanked her for letting me deliver her child.
Safari! And now down to business…
First day at the hospital today! Feels great to be getting our hands dirty- literally, in me and Eli’s case, as we are on the labour and delivery ward. We haven’t delivered any babies ourselves yet, but the staff are all very friendly and very keen to get us involved, so we are excited about tomorrow!
The main difference between the hospital here and in England that I have observed so far is their attitude to blood. Understandably, they are extremely careful. With one in three adults HIV positive, staff barely touch anything, patient or equipment without gloves, and where blood could possibly be involved, they wear two pairs, standard gloves with a sterile pair on top. Hopefully my embarrassment at being unable to put on my sterile gloves at the first attempt will be a one-off; with the amount of practice I am getting, I’ll be able to do it in my sleep by the time I come home!
Last weekend we decided to go to Maun at the last minute. We thought that it would be our only chance to get out and travel in Botswana, and since none of the other three have ever been on safari before, it seemed a shame to come all the way to Botswana without seeing some of the wildlife. We stayed in a lovely little place called Audi Camp, a few Km outside of Maun. We were lucky to get a last minute booking (the tourit information lady said that Audi was the best camp) and we did have to move to a different tent every night. The first night, we stayed in “en-suite tents” which were amazing. Built on a platform, right at the edge of a lake and with an open-air bathroom so that you could see the stars while showering.
We took two day trips. On saturday, we headed into the Moremi reserve for a day of canoeing and bush walking. They warned us to wear long sleeves, and realised why once we were sitting in the open-backed land cruiser belting along the tarmac road towards the park- it was freezing! Once on the sand road, the sun was up, we slowed down and warmed up and began to enjoy the scenery. Rounding a corner, we saw a car stuck in the mud, another car trying to pull it out, and several men in boxer shorts knee deep in mud trying to get an unruly jack to work. We jumped off our truck and they tried to pull with both vehicles, but to no avail. The truck wouldn’t budge. Our driver decided that we should drive on. Ten meters further down the track, and we were stuck in the mud as well. Luckily our truck proved easier to tow out that the other one, and we were on our way again!
After some problems with sand and engines (we had to push our truck backwards to get it to start) we arrived at the delta, and were picked up by two very shallow canoes, their rowers somehow managing to remain standing despite our occasional sudden movements rocking the boats, as we tried to get comfortable, take cameras out, pull sweaters off etc. We saw a group of 10 or so hippos wallowing in the water nearby, and watched nervously as they woke up and began moving around and snorting. The water was shallow but beautiful, dotted all over with lily pads and water lilies and high grass. Our shallow canoes were ideal for observing the surface of the water, seeing the occasional water skater whizz past.
After about half an hour we stopped for our bush walk. Sadly, there were no animals to see, but thanks to our knowledgeable guide, I can now not only tell the difference between the poo of elephants, giraffes, jackals and antelopes, but also whether the poo is from a male or a female giraffe (the female poo has a sharp point “Women like to decorate everything” said our guide.) He also showed us the difference between the worker and soldier harvest termites, and demonstrated to us their ferocious bite. Further down the path, we encountered the sorry little leg of a baby girrafe, a little fur still visible, dragged their by hyenas.
Back in the little canoes (by this time we had learned that they are called “mokoro”) we were rowed to a little clearing where we ate hunks or chicken and ham and cheese sandwiches while our guide shimmied up a tree, then told us that he had spotted a heard of zebra. Eagerly we followed him to a spot where a huge heard (maybe 50!) zebra were quietly grazing. We watched them for some time, and allow some of them stared steadily at us for a full 10 minutes, the others soon went back to ambling around grazing. It was beautiful to see. Soon it was time to head back to the mokoros and face a high speed drive in atruck with a very dodgy radiator back to the camp.
The next day were were prepared for the cold; I was wearing 5 layers, and we were happy to see blankets in the back of the truck! It took us a couple of ours to reach the park, though this time in amuch more reliable truck. On the way we saw cattle and donkeys, and even and elephant and some giraffes. Our time in the park was amazing. Even the guide said that we were lucky. Sometimes, he said, he would take groups on a 5 day safari and they wouldn’t see half as much as we did. At first though, all way relatively quiet. We stopped for a spot of breakfast just inside the reserve, and watched a yellow-billed hornbill (banana face!) collecting some seeds. Hornbills have the same mate for life, and the male provides the female and her babies with food while they are nesting. Our guide told us that for this reason, local women believe that a straying husband should be fed the heart of a hornbill, so that he will absorb some of the bird’s love and commitment.
We drove on, seeing plenty of impala, some giraffes, a lone male elephant. Our guide was a mine of information, telling us how to tell the males from the females, how old they would live to be, what their mating behaviours and social structures were, and other interesting facts. Our guide stopped all the card coming in the opposite direction to ask them what they’d seen, and it soon emerged that a male lion had been seen sleeping. We soon found him, about 5m from the road, basking under some bushes. When we drove near he stood up and surveyed us for a moment, then, uninterested, he went back to sleep. Further down the road, a massive heard of buffalow were quietly grazing. We felt smug to have seen three of the big five in just one short day. We stopped to take some photos of the truck. No sooner were we on the road again than we stopped abruptly. There, not two meters from the truck, was a female leopard. She stayed for a matter of seconds, staring straight at us, the she curled up her tail and was gone into the bushes, and although we stayed around (“You can’t let a cat get away so easily” said our guide) we didn’t see her again. It was amazing and magic that it was so fleeting. No one had time to get their camera out!
On the way back, we saw dozens and dozens of elephants, a couple of breeding heards, wallowing and drinking in the water, suckling their young, pulling down trees and flapping their ears at us. A couple of young bulls (they don’t mature until the age of 25, about 10 years after the cows!) trumpeted at us (“Behaviour learnt from the old bulls” our guide said) and one even attempted a little charge once he could see that we were already leaving! We left the park as the sun was setting, giving beautiful views out across the water, sillouetting the animals as the drank.
