A Chronologically Capricious Smattering of Topics ( BMS, KITSO, Outreach, Chatting with the locals)

About two weeks ago Lindsay and I followed Marape to Kitso training in Kanye. Kitso is Setswanan for ‘knowledge’ and is an acronym for Knowledge Innovation and Training Shall Overcome. It is a government training program for health professionals involved with HIV/ AIDS care. The Baylor Botswana team of doctors is responsible for traveling to sites such as Kanye and giving PowerPoint lectures along with pretests and posttests to determine the efficacy of the teaching. Our KITSO took place in a small conference room of a lodge and we covered topics such as CDC categorization of AIDS levels, nutrition, and ethics and law surrounding AIDS cases to an audience of about 40. I found the last topic the most interesting as there are many issues about disclosure and the children’s right to know, autonomy over taking drugs, employers responsibilities to employ infected people and the governments responsibility to protect the infected people’s rights. Marape was an excellent presenter, throwing in funny anecdotes such as his poking fun at the traditional Setswanan wild spinach dish’s right to being called a vegetable as it has all its nutrients boiled, dried, mashed and simmered out before it hits the table. Lindsay and I filled in the normal interns helper roles, namely staring up the presentation, stapling and grading post tests, ( basically we were there just to learn about how this program operates.) To tell you the truth though, while there was a large improvement in the scores, not everyone passed (got over 50%) the post test even though all the information to pass was taught. In general I sometimes doubt the ability of a PowerPoint to help people retain new information. It makes for pretty presentations and an easy viewing experience for the learner, but I feel like it is too passive a way to get information.  Personally, the slides of a powerpoint can tend to act as a sort of visual lullaby, whereas if there are no slides, it is more of a brain workout to synethesis the spoken word into a memory. Alternatively, the interactive, get up and talk approach seemed to be much more effective as shown by Dr. George’s presentation this morning. Getting right to the heart of the matter, he noted that “Batswanans are great people, but they are also a quiet people.” So to address the normal silence that follows questions during a lecture, he called on individuals to get their answers on diagnosis of children with volvulous vomit leading to a possible life threatening malroation in the gut. As opposed to a standard lecture series which he noted could ‘’muddy the waters and not be practical,’’ I felt that the way he presented information would really stick.

And back to the KITSO day…..With classic rock, the “Piano man” and the Eagles blasting in the background on the drive in our UNICEF van back to the Baylor COE, Marape told us a little about how the village governing system works. (I make note of the music because it was a huge relief from the all too widespread obsession Southern Africa seems to have with James Blunt and his high blood pressure inducing song, “You’re Beautiful”) In a way that reminded me a little bit of the federalist dual system of government, the villages have a chief, a Kgosi, who sits over village meetings, Kgotlas, and settles disputes. In the informational sheets in our clinics patient’s files, there is a question that asks for the village chief’s name, so it must be relatively important. Considering our experience meeting the chief in Mochudi, it seems one responsibility is to serve as diplomats. Another as judge/ punisher. For small crimes such as stealing a goat or chicken - animals so ubiquitous here one starts to think they must be part of the public property- he can administer the good old fashion punishment by means of public humiliation and physical pain: bare butt whipping. According to Marape, a fate that foreigners can be subject to as well. This answers my question on how people could be so what I perceived to be trusting or even careless in letting their animals roam all around. Not everyone is a fan of the village chief though. Elijah, an artist we met on our visit to Pelegano Pottery in Gabane ( see my interview of one of the artists, Helen http://www.youtube.com/watch?v=v374agdbWnQ) expressed his dislike for his Kgosi because he often came to the Kgotlas with a little too much dagaa, weed, in his system.

On an unrelated note to chiefs, but a related note to Gabane, we had an interesting trek to the Pelegano where we picked up some beautiful souvenirs- the clay is made out of the termite mounds! A lovely thought I plan to keep in mind as I sip my tea. Meeting two local artists, brothers Elijah and Sam who have a company called Two in Art that they described as a charity based organization in which they host groups of students/ interested people to do art - sculpting and painting- in their workshop and then donate money as they feel appropriate. Then the brothers pass on the proceeds to “kids on the street”. It sounded great, but we didn’t have time that day to try our hand at the clay and fiberglass sculpting. Elijah showed us an outlook on a hill where he comes every morning to see the sun rise and all animals come out, rock rabbit and black mamba included! So we sat on the entrancingly peaceful rock and he started talking about his political art about Zimbabwe, where he grew up. He said he had memories of seeing bodies being loaded onto a train after a violent war in his village the escalated from a drunken scuffle because of the availability of weapons. His view of Zimbabweans were that they were strong people, but that unfortunately they don’t fight Mugabe, they just flee the country- hence the large influx of Zimbabwean immigrants to Botswana, something the Batswanans are agitated about the same way Americans are don’t like illegal immigrants from Mexico. While chatting with him enlightening- its one thing to hear all ludicrous things Mugabe is doing to Zimbabwe and another to hear it straight from the source- like many of the people we meet here in Botswana we ended up spending much longer then expected with him before we could pull ourselves away back to Gabs.

On the coombi back to Gabs, I chatted with my seatmates- a 17 year old girl and her mother-about HIV education. It was unnerving to me to hear her answer when I asked her about what they taught in school about staying safe. She said it was important to “stay with one partner.” The first thing she said was not to ‘use a condom’, but to ’stay with one partner’. This reminded me of a chat I was having with a guy named Simba ( yeah, like the ‘Lion King’) about the prevalence and thus almost acceptance of people having partners or affairs while being in a supposed monogamous relationship. So while this girl on the bus would think that she is living a safe lifestyle and having sex with one guy, her boyfriend could be occasionally sleeping around and unbeknownst to him - HIV can be dormant in the body up to 10 years before people show symptoms-pick up AIDS. And since guys are much less likely then women to get routine HIV tests he might bring it home to his girlfriend. If she gets pregnant – it is pretty common around here to have a child without being married first- and has a kid without thinking she needs PMTCT, then her kid will have AIDS as well. And hence AIDS spreads. I was also talking with a 21 year old woman who works at the lodge down the street from our house about the Batswanans culture and sex. She quoted an old idiom which is still popular today- men are like an ax that people pass around. This highlights the entrenched acceptability for a man to have multiple partners, something so common the Motswanas don’t often use the word “cheating.” Another phrase I heard from both Swaziland-one of the expats said the Minister of Health there said this when AIDS was first becoming an issue- and from a worker at the Botswana Harvard Lab was, in response to why men often do not use condoms, “do you eat a candy with the wrapper on?” The mother on the coombi also noted that alcohol was a major problem leading to unsafe sex and the spread of AIDS among the youth. The drinking age in Botswana is 18 years, however bars are less strict at carding then they are in the US and it is easy for kids as young as 16 to get served. Alcohol is affordable and available as displayed by the ubiquitous sorghum brewed Chibuku cartons ( affectionately called Shake Shakes because you shake it to stir up the sorghum powder) that scatter the landscape in more rural areas. And while drunkenness and increased promiscuity go hand in hand everywhere around the world, not everywhere are the consequences so dire.

So the other night we were unexpectedly invited to attend the Secure the Future dinner at the Gaborone Sun to honor the work that Bristol Myer Squib (BMS) is doing in Africa, and of other local organizations in the fight against AIDS. It all started out earlier that day when the clinic waiting room mysteriously cleared out ( save for a few strategically placed patients in exam rooms) and one of the staff mentioned upon my questioning something about a meeting this afternoon. Little did I know this meeting consisted of some of the head honchos of BMS, executive vice president Lamberto Andreotti and the program director of Baylor International Pediatric AIDS Initiative ( BIPAI), Dr. Kline and more people on the BIPAI crew. Gaborone is another one of their stops on their tour of all the Baylor COE’s in Africa- they had just been to Swaziland where they enjoyed a performance sitting in a tent with one of the queens. Naturally, I pulled out the camcorder which doubles as a handy VIP pass for situating myself in the center of all the action. But of course, I wasn’t prepared for it and since fate tends to do stuff like this, soon my camera ran out of batteries. Later that evening at the reception before the dinner we got to chat with Mr. Andreotti who seemed pretty friendly ( although I made some favorable prejudgments because I liked the fact he is from New York). The dinner was opened well delivered and frank speech from the Minister of Health ( who apparently tried out for the role of Precious in the upcoming movie based in Botswana, No 1 Ladies Detective Agency) about needing to know more then just the nice sounding statistics about AIDS progress, but a broader view of the statistical reality- numbers of kids that died from AIDS, not just the number that were saved by PMTCT. The Reetsanang Drama Group performed an act that was about dealing with misconceptions about AIDS, but this was only a conclusion I drew from the ‘home based care’, ‘HIV/AIDS’ and a couple other English words thrown into the largely Setswanan act, an odd choice considering more then half the audience didn’t understand Setswanan.

Last Friday I followed doctors Chelsea and Jeff to Outreach training in Kanye, not too far from where KITSO training was. Jeff presented to a small room of about 10 doctors an interesting PowerPoint on MDR and XDR TB and how to treat and prevent it. The presentation’s approach to treating MDR TB I found to be revealing of Botswana’s strong commitment to healthcare, according to a Peace Corp coordinator for Botswana I met recently, the Botswanan budget’s biggest expenditures are on Health and Education ( lets compare that to the US, shall we?). This is especially so in contrast to what I read about in “Mountains Beyond Mountains” which dealt largely with how MDR TB was being inadequately treated in Haiti and Russian prisons. Speaking of TB, this brings up one of the many letdowns that the Meditech system has had since implementation, including a several day ‘down time’ in which the system was offline. About 4 months ago the internet wire connecting the BOTUSA ( Botswana USA) TB lab to Meditech was cut by a lawn mower.

After the presentation Chelsea and one of the Nigerian doctors there saw a couple of the more difficult pediatric AIDS patients. The hospital in Kanye doesn’t have a pediatric clinic or a pediatrician, so it is only on these weekly Outreach days that a Baylor pediatrician can aid in the diagnosis of the child and prescription of which ARVs. We saw a 5 year old girl who was failing second line and needed to be moved onto new medication before her viral loads went up and her CD4s went down too low. Through chart analysis of clinical data ( VL and CD4 an previous lines) and calling the last Baylor doctor who saw her Chelsea helped in deciding which drugs to move her on next- a very important decision considering once put on these new 3rd line drugs (which are often more toxic/ more side effects), these are the only drugs they have to take the rest of their lives. If the patient fails on them- by not taking them correctly and building up a resistance- then they are out of options for treatment. She filled out a special request form to get the 3rd line drugs because they are strictly regulated by the government in order to stop wide prescribing and hence resistance building. Unfortunately, as Chelsea informed me, sometimes the approval process for these drugs can take up to three months which is sometimes too long to wait for some kids. Luckily for this little girl, through the connection to the Baylor Clinic COE, this special order can be expedited.

 And to finish off this post, here’s your daily dose of Setswana ( the g’s are pronounced like a gutteral hhh):

Can I take your picture? Ke kopa go go tsaya senepe

Its okay, its all good: Go siame

How are you? O tsogile jang? I’m good- K tsogile sentle ( tle pronouced like a cl like click)

How are you- slang (literally where are you?) Li Kai? Iim good ( I’m here) Ra teng

Thanks- Kae a legboga ( pronounced more like Kaleboga)

Stay well ( when you are leaving someone) Sala sentle

Travel well ( when someone leaves you) Tsamaya sentle

I like Setswanan food- Karata dijo tsa Sestwana

Another greeting - Wa reng ( literally what you sayin?) Ga k bue ( I’m not sayin anything)

See you later - Ke katlo bona

White person- Mokoa

No problems - Ha hona matata ( like acuna matata!)

I am from America- K tswa America

My name is Rachel - K bediwa rachel

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