Last Day

"Just hold still" she said as she took an alcohol swab to the back of my head, "we didn't want to tell you until the kids weren't around". I asked what the hell was in my hair, and Heather showed me the big green loogie I had been sporting as a yarmulke for the better part of an hour, along with indeterminable amounts of dust, sand, and more than a little slobber. 

Wednesday was our last day in Old Naledi, and we decided to spoil the kids a little by bringing bowls of M&Ms for them to share. We coupled it with a handwashing demonstration and the lesson to always wash before eating to, you know, justify giving them candy... 

What we didn't expect was to play the part of human jungle gyms for most of the afternoon, children holding on to every appendage and two or three on my back at a time. In addition to just being kids who want to play, culturally, children aren't held very much in Botswana. Women tie babies on their back papoose-style for the first year or so. After that, you're on your own. These kids are worse off because parental involvement is minimal or nonexistent, and corporal punishment is the norm.  Consequently, they are desperate for positive human contact and used every square inch of us as a playground. The three of us grew oddly attached to these kids during our month or so in Botswana, and seeing them every Wednesday was a bright spot in our week. Obviously, we each have our favorites, and it took every ounce of willpower not to put one in my carry-on. My favorite is a six year-old with crooked front teeth and an endless supply of energy. His (only) school uniform shirt is always open because all the buttons have ripped off and you can see his toes peeking our from inside of what used to be velcro high tops. We played airplane and spun around and chased after each other all afternoon. When I walked to the grocery store down the street to buy a water, I heard him chasing after me and we walked hand-in-hand the rest of the way, playing kick-the-can. I bought him a water, too, and he drank it as if we had been in the Sahara for a month (most of the kids we assessed are acutely dehydrated, which is only the tip of the iceberg when it comes to their health concerns). As we sat across from each other back at the center, him guzzling away, I realized just how small he is for his age. When we ran the data for all 27 kids we assessed, we found that 82% of them are below the 50th percentile for their height and weight. 36% are below the 30th percentile, and more than a quarter of them are below the third percentile, their numbers so low we could not even plot them on the growth charts. 

Yet, these kids were running around like there was not a care in the world, begging to be the next one up on our shoulders. For all their severe malnutrition, a surprisingly low number of them needed referrals for things like cardiology or acute infections. The human body is amazing; it knows to prioritize the important things like pumping blood and keeping the kidneys working. Many of these kids may have patchy bald spots because they don't have enough protein in their diets to both keep vital organs functioning and make hair, but the body knows which of these is more important. 

I choose to believe that the Center we worked at will be the positive influence these kids need to escape their current circumstances. That is more than a little idealisting, but fledgling as it is, it is too important to fail. We left behind all the medical supplies we could muster and a new physical assessment form that is much more comprehensive than the current one and asks important questions about sexual health and substance use. We aggregated the data we collected and are putting into a report for the site director to share with the Ministry of Health to argue for things like toothbrushes (82% had some sort of oral health issue) and soap (because, well, they don't bathe). The supplies will run out, the Ministry may not listen, and the local nurse (if they can ever get one to show up) may not use our form, but I choose to believe we left something behind that will have a lasting impact. It would only be fair, because that place certainly had one on me. 

The Giggle Project

It's so hard to believe that this is our last week here. In the time since we arrived, my classmates and I have created three distinct and targeted curricula aimed at young mothers, vulnerable youth, and young fathers, respectively. This amounts to more than 150 pages of activities, discussion questions, and facilitator notes. They cover everything from family planning to STI prevention to anger management, goal setting, physical fitness, nutrition, and how to change a diaper. It's incredible that what we've created here will be implemented and go on to hopefully make a difference in the lives of the community we are trying to serve. I am proud of us, fo sure, but I am more humbled by how this organization has been able to serve the needs of these extremely at-risk youth with so few resources. Our boss said she had been wanting to implement something like what we've created for more than a year, but that there was no one available to do it. In creating the curricula, we had to be mindful that there are almost no resources like anatomical models, technology for presenting the material, or examples of most types of family planning. Things like flipchart paper and markers were used sparingly since they are in short supply. Working within these confines taught me a lot about how to do more with less, and also gave me a newfound respect for people who work with youth like this (or any youth, really) in the States and around the world. 

We piloted our demonstration activity yesterday, which involved handing out sexual risk behaviours (think "sex with a condom" "anal sex without a condom" "mutual masturbation" and "Hugging" to name a few) and telling the kids to run to either a green, yellow, or red sign based on the amount of risk they perceived each activity to have. I was really impressed with a) how much they knew about sex at 14,15, 16 years old and b) what they knew about how STIs were transmitted. The giggles were expected, and it was pretty funny to explain oral sex using hand gestures to a 15 year old... 

It's easy to forget sometimes that this country was ravaged (and in some ways still is) by HIV, and these kids' parents' generation is largely deceased. However, there has been so much emphasis on preventing HIV that education about other STIs and unplanned pregnancy have gone by the wayside. That gave us an opportunity to talk about other risky behaviours and what might happen if you're not careful. 

I have learned so much in the past four weeks- not only about nursing, but about healthcare in a larger sense. It is totally different to see the healtcare system from a more clinical perspective and with a knowledge base I didn't have in Bangladesh. It confirms that this is really what I want to do with my life, and I am so glad I had this experience to mesh my passion for Global Health and clinical practice. 

Oh, and I saw like 4 million hippos and the world's largest waterfall last weekend. That was pretty awesome, too. :)  

Ups and Downs

Today I felt like a nurse. Like, a real one- someone who can assess a patient, notice when something is wrong, explain it well to someone else, and refer the patient to someone who can help them. It was one of the best feelings I have had on this trip. 

During the routine assessments of the kids at our site, it is common to come across things like tooth decay, vision problems, dehydration, and other common ailments. Some, like dehydration, we can do something about. Others, like vision and dental problems, are serious issues but there are just so few resources that these kids are never likely to see a dentist or an optometrist anyitme soon. For this patient, however, we could tell something was not right. Despite his normal demeanor, he had to be in serious pain. He complained of bloody urine for the past month, painful urination, and he had a low grade fever (or rather, we think he did- the thermometers here are crap). Then, as I continued the physical exam, I checked his back and could physically see the outline of his kidneys protruding from either side of his spine. They were so swollen and tender that it was a wonder the guy could even lay down. 

My classmate and I recommended he go to the neighbourhood clinic immediately, and we wrote up an official referral sheet, something with which he would be seen much more quickly. Then, the center director asked me to accompany him to the clinic so I could converse with the nurses there on what I had seen on exam and recommend a course of treatment. When we got to the clinic, the first thing I noticed was that the ceilings were high and all the windows were open- to combat the spread of TB by having as much of a cross-breeze as possible. There were signs everywhere saying "Don't worry- tuberculosis is completely curable" and "know your HIV status: get tested". It was much different messaging than I would see in the States. The busy clininc was staffed only by two nurses, but since they have prescriptive authority here, a physician isn't needed to put in orders or write prescriptions. After going over the exam with the nurse, he asked me what I think should be done and showed me which medicines he was going to prescrible. I must have looked like such an idiot, standing there pretending to know what the hell I was looking at. I may be almost done with nursing school, but I have no idea what to prescribe for a month-long kidney infection, let alone which strengths and for how long. Yet this experienced nurse was looking at me as if I had all the answers. I eventually just said I wasn't sure, but that what he had prescribed looked like it covered all the bases. There were several antibiotics, after all- that much I knew. 

Because the infection had spread to the kidneys and carried a risk of sepsis, they referred the patient to the hospital. The one problem with that is there was no way to get him there. All the city ambulances (all two of them, I'm sure) were otherwise engaged, and the clinic had no other way to get him there. So they gave him three injections of antibiotics, prescriptions for three more, and sent him home until the next morning. I just stood there, dumbfounded. Home? I'm thinking to myself that this guy needs a hospital, now! I'll call him a cab, I'll borrow him a car, I'll piggy-back him there for all I care, but he needs to be seen my a doctor. Instead, the nurses shrugged their shoulders and sent him to the dispensary to get his prescriptions filled. Except they didn't have all the prescribed meds, so he went home alone. in pain. until the next morning. 

While it felt amazing to see something abnormal, recognize it, diagnose it correctly, and follow the patient through the referral process, it was frustrating to see the breakdowns in the health system. Botswana's is better than most in Africa, but it was still disheartening to see this guy fall through the cracks. Who knows if he will actually come back to the clinic? He may just decide that it's not worth the standing around, waiting for something to happen. I can't say I totally blame him. I can feel good about the fact that he got some of his medications and that I did everything I could to make sure he got the care he needs. I just wish I could know he got the treatment he (and everyone) deserves. 

Blessed

It hit me today that this trip ticks the last box off of a rather short, but hard-to-accomplish list. As of this writing, I have visited every inhabited continent on this big blue marble. Though I have yet to see even a quarter of what I hope to in my life, I have had some incredible adventures since my parents lovingly waved goodbye as I, at 13, hopped on a flight to Sydney that begun my lifelong love of travel. 

Since a slightly overweight, giddly, and more than a little terrified adolescent boarded that plane, I've looked down through the clouds at Machu Picchu and up into the rafters of the Sydney Opera House; walked the ancient highways leading to the Coliseum and jumped into the chilly waters of the Baltic. I've hiked the snow-capped Himalayas and listened to the mesmerising chants of orange-clad monks in the shadows of a Buddhist temple. I've explored the lush, rolling hills of West Virginia, kissed my wife on the Space Needle, and even walked straight through the middle of a California Redwood. 

I've stared in awe at sunsets in all four hemispheres and looked up at the moon in 24 different countries, always remembering that it is the same one my mom is looking at back home. For me, traveling isn't about ticking boxes; it is about finding out how much I don't know about what we continually misconstue as a 'small world'. Despite technology making communication easier and information more instantaeous, traveling is an intensely humbling experience. It takes only a few cultural missteps before you realize just how little you know about somebody else's corner of the globe- no matter how much research you did before leaving. However, those missteps are golden opportunities to learn something you didn't know about someone else and opens up the possibility for you to tear down their preconceived notions about you (as a man, an American, a white person, etc.) as well. 

One thing I have learned about myself is that my desire to travel is not motivated my wanderlust, but by an intense curiosity and a desire to know as much as I can about as many places as possible. I do believe that there is a practical application to gathering this information. Every experience a person has impacts the way they think and act. The more plentiful and varied your experiences, the more you can relate to, and appreciate, those who are different from you. This has the potential to diffuse tensions across the world, and I truly believe that real progress could be made if people who hate each other just traveled to their enemy's hometown and spent two weeks walking around. 

I am beyond lucky to have been able to exercise my greatest passion as much as I have. There are still so many places I want to go, and with every trip the list grows longer. I may have set foot on nearly every continent, but I haven't come close to seeing everything there is to see. I can't wait to find out where life takes me next, and I am so blessed to have a partner in crime who shares this same thirst for new places, knowledge, and experiences. Antarctica- we're coming for you. 

Safari!!

This weekend was one of the most incredible experiences I've ever had. We drove about an hour and a half out of Gaborone, across the border to South Africa, to Medikwe Game Reserve for a weekend safari. This trip is included in our program fee for the trip, so it felt 'free' even though we are deeeeefinitely paying for it. 

The lodge was like a mirage, and we could practically hear angels singing as we walked in. Real mattresses! Hot water! Each individual chalet (I got my own as the perk of being the only boy) had a veranda that looked out on an artificial watering hole the lodge created to lure the animals as close to the resort as possible, as well as an open concept rain shower (which means it was private and luxurious- but most definitely outside).  A family of monkeys lives on site and I saw one particularly cheeky one eating a bag of doritos on the wall next to my room as I checked in. We all basically turned into vegetarians because the buffet-style meals had a salad bar, and we have all  forgotten what lettuce looks like. As we chewed our rabbit food, we watched zebras and elephants frolic in what little water exists here in the dry season. 

Each morning at 06:30, our driver- an experienced tracker with a gold tooth named Ernest- would call us for breakfast before heading out on a three hour drive of the park, tracking whatever was close or we requested to see. It sounds funny, but after the first couple of hours, elephants become almost commonplace. We were lucky enough to see cheetahs, lions, rhino, zebra, various types of antelope, impalas, kudu, ostriches, warthogs, water buffalo, and a pack of adorbale, yet apparently deadly wild dogs. These German Shepherd-looking pups can clean an enture antelope to the bone is fewer than ten minutes. I decided to not attempt to pet it. The cats were playful and rolled around on their backs to catch the waning winter sun- they were so cute that you almost forget that they can literally rip your face off. 

   

The amazing thing about all this was we quite literally drove within ten feet of most of these creatures. Because  they are so accustomed to the safari trucks, they hardly even pay attention to us. I wonder if some of the more exotic animals feel like celebrities must when the paparazzi won't leave them alone... 

                                                        "go.....away"

We went on a sunset game drive in the afternoons, stopping halfway to have 'sundowners' (happy hour) somewhere in the bush with a lovely view of the sunset. With a whiskey in your hand and the sun low across the African savannah, it's hard not to feel like the luckiest person in the world. The second night we had a bush dinner outdoors, with big fires burning and blankets to keep us warm. We tried some of the local game, like kudu, oxtail, and antelope. And veggies. So. many. veggies. On Sunday morning we were dragged kicking and screaming out of the lodge, piling into cars and waving goodbye to a family of baboons that seemed to be almost staged at the exit of the park. 

Seeing these creatures in person is one of the most awe-inspiring things I have ever experienced. However, while those within the bounds of these 70,000 hectares are more of less protected (some poachers still get in), more than 100 elephants are killed in Africa every day- just for their tusks. Rhinos are even worse off, and if something isn't done soon, there won't be any of them left to see. 

I am so blessed to have had this experience; it is one I will never forget and hope to repeat someday with my own family. 

Handouts

Something has been bothering me about Botswana for the past few days. What started out as forseen quirks of the developing world- breakdowns in communication, the lack of punctuality, the breezy attitude most people here have- are starting to really bug me. I don't think it is impatience, because living in the developing world requires an inordinate amount of patience on a daily basis (it legit took me 15 minutes to buy a bag of chips at the market today...when we were the only ones in the store..) 

No, I think it is more of a frustration with what I perceive as a lack of drive or motivation. Many of the people here are just resigned to the broken systems or status quo that is obviously not working for them. They are content to plug along, not really wondering why things are this way and with little desire to change them. 

Then my classmates and I were talking and we realized that, here, the government takes care of nearly everything. Housing? covered. Healthcare? covered. University? covered. Almost every single facet of society is provided for by the government, which for now is flush with diamond money. This welfare extends beyond basic services, though. For example, all nurses are employees of the Ministry of Health, not the clinic or hospital at which they work. All receive an automatic 30% overtime bonus and all are automatically promoted every two years, whether they deserve it or not. What kind of incentive does that provide to be better? How does that encourage anyone? This kind of welfare state fosters what one Batswana we met calls a "culture of complacency"-and I completely agree. The exceptions to this rule- and there are many- fight hard for change, but either fold under the weight of their David and Goliath-like struggle or burn out trying. 

I understand why the government operates the way it does. Fifty years ago, this country didn't exist and the annual income was less than $200 per person per year. Add to that a virus which virtually wiped out an entire generation- the medications for which no citizen could afford on her own- and you can see why the government swooped in and took over almost every facet of society. The balance between government doing what it should do- caring for the least fortunate of its citizens- and personal accountability has been tipped. Now, it could be worse. According to Transperancy International, Botswana is by far the least corrupt country on the continent. While little seems to get done, at least the money isn't being gobbled up by a few oligarchs at the top. 

Botswana has some major decisions to make fairly soon. The diamond mines are set to close within 20 years, and most people agree that the economy hasn't diversified enough to make up for this revenue loss. An bloated, inefficient goverment which sucks up a huge amount of GDP and employs more citizens than any other entity in the country will struggle to maintain itself in a post-diamond economy. 

I have hope that things can change and people can once again find that motivation that helped turn this once seemingly worthless piece of desert into the envy of the region. However, they should do it soon, or else it might be too late. 

Chew Toys

Friday was my first day back in the real world, and I am so glad I was well in time for it. Friday is one of the two days per week that we go to our alternative site in Old Naledi- Gaborone's poorest neighborhood. 

My friend and I did physical assessments on all of the children in the center. It was the first time that we actually got to practice our clinical skills. These kids range in age from 6 to 18ish, and due to the conditions in which they've grown up, they all present with things we might not see in the States. 

The morning was spent with the younger kids who should be in school, but for one reason or another don't ever get there. They were SO excited to go visit the 'doctor' and could barely contain themselves when I let them play with my stethoscope. We started with vital signs, except that the blood pressure cuff we had could wrap around each child's arm about three times and they were terrified to put the thermometer in their mouths so we had to do it under their arm (which takes forever and is less accurate). We then went systematically through each body system: Neuro, Skin, Cardio, Respiratory, etc. We were lucky enough to have a translator, but even so, we had to model on each other what we were going to do first and make sure each kid understood what we were about to do. For a 10 year old who has never been to a doctor except to get her vaccinations, you can understand how apprehensive she might be. Also, considering most of these kids haven't bathed in, i don't know, ever, they're probably a bit embarassed. 

 One particularly endearing 8 year old was in a serious car accident and has since had a mental deficit. He was hyperactive, nonverbal, and nearly impossible to focus....not entirely different from an untrained puppy. Though he did manage not to pee on our carpet. For whatever reason, he took a shine to me and would sit still on my lap long enough for my partner and me to assess him. I did, however, find the answer when he faceplanted my hand and started gumming it like an old man with applesauce. Well, whatever gets the job done. Also, please pass the Purell. 

I thought I was special until I saw him gnawing a piece of garden hose off the ground outside not an hour later. #heartbreak. He made it up to me by being obscenely cute. 

In the afternoon, we assessed the older kids, which we could do in English. It was really cool because we got to talk to them about reall issues like sex and drug use that we know from the center's management is happening, but they're not open with them about it. One kid came to us and told us he really wanted to quit smoking cigarettes and pot. We outlined ways that might work and gave him a timeline, and told him we were here every week and would check up on him next Wednesday. 

I really felt like we helped out on Friday, and it reinforced why I began this journey called Nursing in the first place.