Botswana Outreach Clinics, or "What the hell is that?!?"

Each Thursday, the Dermatology resident on staff with the Botswana-UPenn partnership travels out to one of four different "outreach" clinics that are in hospitals outside of Gaborone but still within Botswana. So far I have been to clinics in Mochudi, Kanye, and Lobatse. These outreach trips have been my favorite part of the rotation and provide for quite an interesting and rewarding experience, not just because they allow you to provide a much needed dermatologic service to an isolated population with otherwise very limited access to care, foster goodwill and positivity between the volunteer medical community and indigenous people, and connect with patients in a rural setting that allows a deeper understanding of the socio-economic and ethno-religious climate effecting their health status... but also because you get to see some really weird shit.

My first trip was to the clinic in Mochudi, which is a small town about 45 minutes to the north of Gaborone just off the main highway that connects Gaborone with Francistown. Mochudi's hospital is built up on a hill above the town, reportedly because their chief was unwilling to donate land for the construction of the hospital way back when it was built.

Just up the road from Gaborone

I came across this patient there, who had these painful, draining nodules on her foot for 10 years. She proceded to show me how black stuff would ooze out of the wounds if you applied pressure around the nodules. Fortunately that gave me a pretty good idea of what it was, which is a Eumycetoma, or "Madura Foot", caused by a chronic deep suppurating fungal infection. Unfortunately it made me nearly lose my breakfast. The black stuff is actually little grains of fungal hyphae.

Eumycetoma, or "Madura Foot"

Black grain

So gross

I also ran into this little character there. Mom explained that this was his winter outfit. Keep in mind that I was sweating in a thin oxford with rolled-up sleeves at this point. It's all about perspective.

I asked mom if he liked bears and she had no idea what I was talking about. You see, there aren't any bears in Africa. She thought it was a monkey costume.

On the way back from Mochudi we stopped at a small village called Oodi. In Oodi there is a "weaver's collective", run entirely by women, who weave traditional Batswana scenes out of dyed wool using hand-made looms. It was a pretty impressive little operation and they were definitely in for the hard sell. I barely made it out with my Pula intact.

Traditional weaver in Oodi.

Weaving in progress

The following week we drove west out of the city to Kanye. Sometimes when you are driving on the highway you will see signs that say "Molepolole West" or "Palapye West", with an arrow that apparently indicates a road to the western part of the city. Unfortunately Kanye wasn't big enough to have a western part, or at least didn't warrant a sign. Or it had already been stolen before I could get to it.

Kanye, about an hour outside of Gaborone

Kanye actually turned out to be a pretty sizable town, and had a fairly nice hospital. A lot of the buildings had skylights, allowing tons of natural light into the exam rooms. If I ever design a Derm clinic it's going to make use of these.

Surgery wing at Kanye Hospital 

The clinical exam rooms are pretty much the same everywhere, but I'll include one here. They all seem to be build on similar plans. They all have a desk, two chairs for the patient and guest, an exam table, and a sink. The most annoying thing I found was that there were never any procedural trays (mayos) available. It made it very awkward to set up biopsies. 

Exam room at Kanye Hospital

Kanye's Hospital was sponsored by the Seventh Day Adventists and there was an American internal medicine doctor there from Loma Linda Hospital (also SDA). He had signed on for a five year stint there. I couldn't even imagine.

You will frequently encounter patients in the outreach clinics that have had tumors growing for years without ever having them evaluated. This leads to some impressive, yet quite sad, cases. This is an albino patient with a mass on the lower back that was about the size of a small grapefruit.

I'll just take a little off the top

It was biopsied and turned out to be a large basal cell carcinoma. Which is about as good she could have hoped for. At least it probably hasn't metastasized already. I can't say the same for the handful of other patients with giant tumors of the vulva that they had neglected for years. I saw a 27 year old woman with a tumor covering her entire vulva and perianal skin. She was already jaundiced and cachectic and I suspect had mets already. None of the pictures are appropriate for a public blog but are available on request.

This past week I went south out of Gaborone, all by myself this time, to Lobatse. Lobatse is up at a higher elevation than Gaborone and is subsequently even colder during the winter. I made it to the hospital much earlier than expected and had to wait outside of the morning report room in my thin fleece. I shivered there for about 10 minutes before this little old woman came and pulled me into a small room where several nurses were huddled around a small space heater. I gratefully joined them.

After morning report, one of the local doctors approached me and asked, if I'm not too busy, could I come and see one of her inpatients? She explained that the patient had a mass in the left axilla that had developed an ulcer and they wanted my opinion on what it was. I had just gotten through giving a lecture on cutaneous signs of systemic disease which included a section on cutaneous metastases of internal malignancies and I figured that's where she was leading me. Oh, how wrong I was. What I found was this frail little 92 year-old woman with the following "mass" of the left axilla:

What the hell is that?!? 

No, seriously, what the hell is that?!?

Apparently it had been present since birth and had only recently started giving her problems, being entirely asymptomatic prior the formation of the ulcer. I decided that it was most likely ectopic breast tissue that had ulcerated due to ischemia. But maybe also a giant skin tag or neurofibroma? I'm at a loss. I've decided to submit it to the Africa Telederm website. Should generate some lively discussion.

Well, that's it for now. Next week I head up to Mahalapye, which is about 2 hours away. We only go there once every 2 months, so I'm sure there will be lots more weirdness to share.

Until then, signing off, from Madikwe, South Africa.