Stanford University
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NAPAZ Annual Conference (23-24 September 2011)

This weekend, I attended the National Physicians' Association of Zimbabwe's annual conference and general meeting, held in Bulawayo. I was the only medical student who attended (although it turned out at registration that students do not have to pay to attend!) and this year, the meeting was exclusively for physicians (compared to the year before when they had surgeons and anesthetists present --- apparently the physicians destroyed the surgeons on the golf course, an obvious disincentive for them to come back this year!)

The conference theme was "Non communicable diseases: revisiting a forgotten epidemic through strengthening continuing medical education." The first day focused on non communicable disease, and the second centered on medical education (as did the Zimbabwe Medical Association (ZIMA) conference a couple of months ago --- I am sure that this emphasis is largely because of the MEPI program and the enthusiasm with which medical education transformation is being tackled, at UZCHS and Pari, in particular). Drs Gray and Ndhlovu encouraged me to attend, and in retrospect, it was a weekend very well spent!

Program
Day One
Welcome remarks - NAPAZ President (Dr Ndhlovu)

Session One
Management of Status Epilepticus (Dr G Mamutse)
Applying Quality Improvement Methods to Hypertension Management (Prof Ed Havranek)
[Dr Mamutse was a "Wunderkind" during his time at UZCHS med school and during his MMed. He left for Norwich in 2001 and is a neurology consultant. He was in Zim for two weeks on the wards and teaching. Prof Havranek is a visiting professor from Denver, and one of the lead faculty in the CHRIS program.]

Session Two
Update on Assessment and Management of Acute Stroke (Dr G Mamutse)
Rheumatic Heart Disease: An Overview (Prof Ed Havranek)

Session Three
Neuromuscular Respiratory Failure (Dr G Mamutse)
An Overview of Lymph Node and Bone Marrow Aspirate findings in patients referred to Bulawayo hematology clinic (Dr Paleski) [So eccentric!]
Genomic and Phenotypic Correlates of colorectal cancer in Zimbabwe (Introduction to a PhD thesis) (Dr L Katsidzira)

Day Two
Assessment of juniors (Dr C Ndhlovu)
Overview of MEPI/ NCI Programs (Prof Matenga, Prof Hakim)
Proposed future training of specialists in medicine (Prof I Gangaidzo) [this session was excellent, and generated lively debate]
Summary/ way forward (Dr C Ndhlovu)

Thoughts
One of the best parts of the conference was being able to see the physicians in a less harried, calmer state than is the norm when they are on the wards. I was also in Mentee Nirvana. I was speaking to Dr Gray at some point about my future plans, nebulous and amorphous as they are, and he mentioned that the diffuseness of my thoughts means one of two things. Either I am planning such a grand and expansive scheme that it is impossible to actually put in words what my aspirations are, or I simply do not know what I want to do! I was hoping for a bit of grey area, somewhere in the middle of these two extremes, but talking to some of the physicians did give me more food for thought.

The challenge with the Zimbabwe situation is that we have decades of lost manpower - we have at the peak the Professors Hakim and Matenga, but gaps in the decades separating them from the Drs Ndhlovu and Mamutse, and then another barren patch between them and the training students. There were a few stories told about enthusiasts who trained abroad and returned to Zim, generally lasting less than a year because the system in Zimbabwe currently does not lend itself to full use all the knowledge acquired abroad, and the threshold for "standard of care" is different because of resource availability. The challenge then, is to find middle ground between the very different ways medicine is practised in Zim and in, say, the US. I think that ultimately no amount of planning will allow one to predict what the situation will be in 5, 10, 15 years time... I am safer sticking to "nebulous" planning at present...

Bulawayo/ Matopos (week 9)

I was in Bulawayo from Thursday to Sunday for the NAPAZ (National Physicians Association of Zimbabwe) annual conference. Bulawayo, known as the "City of Kings" is the second largest city in Zimbabwe (after Harare), and perhaps because I am from Harare, I find Bulawayo more interesting and impressive (we know what familiarity breeds...) Bulawayo has large, sprawly streets, is steeped in history, the people are pleasant, and Ndebele has a melodic lilt to it that I love, clicks and all! The landscape around the city is also very beautiful (the rock formations of Matopos in particular). Bulawayo is close to both South Africa and Botswana (and used to have a robust railway system), and is also en route to Victoria Falls and Hwange. Taking a look at Zimbabwe history, so much happened there - from Mzilikazi settling there after fleeing South Africa, to Lobengula's unfortunate treaties in the late 1800s.


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The Watering Hole, a bottle store in Bulawayo. We got tickets to the Oliver Mtukudzi/ Winky D concert here.

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Site of Cecil John Rhodes' grave (of De Beers, Rhodes university and Rhodes scholarship fame, Zimbabwe was formerly called Rhodesia --- well, Southern Rhodesia till 1965, and Rhodesia till 1980 [Zambia was Northern Rhodesia])

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Another view of Rhodes' grave. A excerpt from Rhodes' will: "I admire the grandeur and loneliness of the Matopos in Rhodesia, and therefore I desire to be buried in the Matopos on the hill which I used to visit and that I called the "View of the World," in a square to be cut in the rock on the top of the hill, covered with a plain brass plate with these words thereon "Here lie the remains of Cecil John Rhodes,"..."

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The landscape has an eerie, haunted feel to it.

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I have not decided if the end of the day in Zim is particularly beautiful, or if I am peculiarly primed to appreciate it. No, love it!

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Cave paintings by the San (bushmen), probably dating back 2000 years.

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The weathering process creates amazing rock formations from the granite. Mzilikazi gave Matopos its name, which translates to "bald heads" --- there are incredible whaleback dwalas, one of which (Pomongwe) I recklessly climbed/ scaled barefoot...

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Server deployment and integration

This week, Stanford's Michelle Cook has been working with the NECTAR IT team (Rumbi and Miriro) to set up the servers for the MEPI system. There are to be 4 servers, with 4.2 TB of storage and 24G RAM. There are also two storage arrays, comprising hard disks with 48TB of storage (for use by staff and students, with each student having fixed storage for the 5 years they are in the program.)

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The servers (top 4) and storage arrays (2, with 24 disks)

Michelle Cook also brought with her a copy of UpToDate to be part of the materials available on the intranet. This will be of critical importance on the wards, and also for the students throughout their training years. Additional resources will be added as they become available, including supplementary curriculum materials for the 1st and 2nd years from Stanford.

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The "wonder team" - Michelle, Rumbi and Miriro

The intranet will allow internet access to speed up in the entire Pari/ UZCHS network as most of the reference materials will be available locally. Switching to webmail will also have a similar effect. The implementation stage to get everyone on the network will involve multiple steps - programming was completed on Friday, and will be followed by 2-3 weeks of core testing. If this goes as planned, roll out from department to department will then happen. This will be in line with NECTAR's role for improving internet access and connectivity, and will also encourage the use of more modern learning and teaching methods by making them readily accessible for both faculty and students.

Island hospice service

"No man is an island, entire of itself"

For two Monday mornings the part 5 students rotating through medicine have sessions at Island hospice, a service that provides palliative care to terminally ill patients. Island hospice provides training about end of life care for medical students (in 5th year), community volunteers, nurses and other health professionals and church groups. Although the hospice service has a relatively long history in Zimbabwe (begun in 1979), some doctors still do not see the value in palliative care, and Island Hospice has late referrals made when there is no longer enough time to make a difference to the patients.

Island hospice provides equipment (eg. wheelchairs), regularizes pain medication, and has counselling services for the patient and family. Previously, other services included "dream flights" for their pediatric patients. Initially, services were also provided free of charge (and Island hospice is donor-funded), but in recent years, that model has become unsustainable and patients are asked to pay ($15 per home visit). The demographics involved have also changed since the early 80's, when most of the services were for cancer patients, but with the HIV epidemic, a large number of the terminally ill are HIV positive. This means that the services have to cater for different needs, for example, training young children to care for their ill parents, or younger siblings.

One of the main aims of the sessions was to make the students confront their notions about death, grief and bereavement, coping mechanisms and think more about how they should break bad news. A series of questions was presented, and the students worked in groups prior to presenting their responses:
1. What does death mean to you?
2. What was your first experience of death, how old were you, and how did you feel? [One of the interesting things pointed out was that for many children in Zim, whenever they think about early experiences with death, they remember feeling hungry or missing a meal --- this is because the funeral customs not infrequently mean that children might not be fully cared for during mealtimes, as funerals are generally adult-focused. Despite this, children actually begin to perceive death earlier than adults would like to believe. This misperception means that there are often "adult funerals" where consoling the children is not made a priority, and avenues for grieving are not provided the same way they are for adults.]
3. How would you like to die, at what age, why?
4. What important things would you like to have before you die?

Week 7 and 8 – On the wards

I have spent most of the last two weeks on the medicine wards as an elective student. My first week coincided with the return of the students for their fifth year. The UZCHS curriculum has two medicine blocks in it – the first was in third year (when the students are first introduced to clinical medicine), and in fifth year, they have their final rotation through medicine.

The ideal Medicine team structure is:
1 consulting attending
2 MMEDs – One junior and one senior
5 JRMOs – Usually 2 – 3 on a ward team at one time
One JRMO rotates through the OI clinic and is on wards only during calls One JRMO rotates in rad onc
5 5th year medical students
5 3rd year medical students
[JRMO = junior resident medical officer]

Our ward team approximates the ideal structure, though it is broader at the base than at the top: the JRMOs seem to be a little overstretched, and often appear flustered. There are six fifth year students, and two elective students, which makes for a larger team than usual (in passing, while arranging my elective, I was told that there has been a rather large influx of foreign students coming in this year for electives).

The rounds have generally been from 8 till close to noon – on the first day, the JRMO presented the patients, the plan was largely derived from the consultant, and there was a satellite nurse helping with the charts (all the charts are kept in a large mobile trolley that dwells at the nurses’ station most of the time). After the first couple of days, the students had clerked patients, and were able to present them, so the interaction became less stilted towards the upper half of the hierarchy.

One of the things my team members told me is that in many ways they are still playing catch-up: their first medical rotation coincided with the time when hospitals in Zim had to be shut down because there just were no resources to keep them running any more. This meant that there was a dearth of patients during their crucial first medicine and surgery rounds, and although they did get some teaching, it was not under ideal conditions. That said, they are very methodical and precise, as well as keen and eager to learn. They absorb the bedside teaching voraciously, and as the rounding time lengthens, they bring out their various handbooks to flip through conditions that were encountered. They are also a very close-knit group – the teams were created during their Part 1, alphabetically based on last names, and by Part 5, they know each other quite well. In addition, there is communication across teams, and often when going through other wards, students will tell their counterparts about particularly interesting findings in a patient that they should go and see together later in the day. I have unfortunately not gone during the call nights (spending mornings only on the wards, with some afternoon lectures on certain days), but there certainly is a lot of time with patients worked into the curriculum.

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Ward C8 medical students

The wards use a paper system, which makes for some confusion when keeping track of some of the results (a lot of tests eg. INR need to be done in private hospitals, so there is considerable back and forth with relatives taking blood samples away, the results being returned and making their way back to the charts so they are accessible when needed during the rounds). One of the goals for Pari in coming years is to get the laboratory system up and running again, so that more of the diagnostic tests can be done there.

The student schedules are put up on a billboard outside the medicine department, and there is also a very efficient (but far from intuitive) system of keeping everyone aware of where the lectures will be (mostly through text messages, I think --- I generally latch on to someone from my team for the lectures). There are usually noon lectures scheduled, and there are also continuing peds, ob-gyn and surgery series/ tutorials. In addition, “special clinics” are scheduled for certain mornings. On my first Thursday, my team went to Dr Margaret Borok’s clinic. Since the early 1990’s she has run the referral clinic for patients with AIDS and Kaposi’s sarcoma. During the clinic we were able to see a number of cases and learn more about the management. Most of the cases were quite advanced – most vivid is a man whose legs had become bark-like and stiff, and whose abdominal area was also becoming rock hard with the tumor growth. He now needed a wheelchair for mobility. The chemotherapy regimen for the patients was determined during the visit, based on the Dubois body surface chart. One of the recurrent themes was the patients’ concern about whether their bodies would ever look the same – if the swelling would recede, the depigmentation be reversed. Some of the newer patients hoped that the chemo would have a “magic bullet effect” and restore them to prior levels of health. Unfortunately, in all the cases we saw, the best that could be promised was gradual improvement over many years, but never back to baseline.

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Week 8 in pictures (Chinhoyi Caves)

Off form again, so shall be lazy and make use of pictures instead! The last two weeks have involved ward rounds with the C8 team, so there has been a time squeeze with half the day gone "as easy as kiss my hand."

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This is the typical traditional Zimbabwean hut - with dagga walls and grass conical roof. The thatch roofs are slowly being replaced by corrugated iron sheets which require less maintenance, but are also less pleasing to the eye.

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With Jake, Michelle and Mambi at Chinhoyi Caves. Michelle, our IT expert, has come in for a week to set up the servers (hallo intranet!), do some "computer sanitizing" (so many viruses going about), speed up internet etc. She gamely spent the day with us after arriving Saturday night!

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View of the Sleeping Pool from the Dark Cave. I actually saw more of the caves this time around because Jake and Michelle were uninhibited by the superstitiousness that makes most Zimbos not-so-willing to explore the darker recesses.

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The Chinhoyi Caves are about 140km away from Harare, and are a system of caves and tunnels (the most extensive in Zimbabwe), with predominantly limestone and dolomite rock. The Sleeping Pool, visible through the Wonder hole has clear cobalt water and is startlingly beautiful.

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Another interestingly named bar, en route to Banket.

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...because I love purple.

On the wards, some thoughts

Differences in practice

I was sitting with my ward team one morning, and they were discussing how different Dr Gray’s method of practice was from that of the typical medicine attendings. Apparently, he spends more time explaining things to the patients than is habitual. Exceptions to this are ob-gyn and surgery, where more time is spent explaining procedures to patients. I think, though, that a major reason for this is understaffing at the hospitals, and the deluge of patients that denies physicians time to go into greater depth in their explanations to them. I am sure this will slowly but surely change as things get better here.

Nail findings

Zim doctors generally begin the physical exam by looking at the hands (in contrast to the US system where you generally begin from the head). Dr Borok gave the students a bedside clinical skills review session, where she went through the first part of the exam, from general appearance, environment, gait, hands and head. Dr Borok mentioned that an advantage that UZCHS has is that there is a wealth of patients so the students can get a lot of clinical practice, and it is that which makes an excellent physician. Stanford and other US universities are also moving towards greater emphasis on the physical exam and less dependence on technology for diagnosis. Dr Abraham Verghese is Stanford’s physical exam champion (Refer to the Stanford 25 website http://stanford25.wordpress.com/), but I wonder if there ever will be a real emphasis on physical examination in our curriculum or in practice where defensive medicine is a norm.

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Medical devices and innovation

Dr Michele Barry, my Stanford PI, was recently published in NEJM. She co-authored a paper on “Health Technologies and Innovation in the Global Health Arena” http://www.nejm.org/doi/full/10.1056/NEJMp1108040. Going through the wards, I have been impressed by the excellent physical examination skills, and how the training here allows the clinician to weave a differential using more physical findings and fewer tests than would be the case in the US. That said, there are clear cases where technology is needed – for x-rays, EKGs, colonoscopies. In these cases, it becomes clear that overall health goals cannot be met if the technology for diagnosis, prevention and treatment is not available, or if there is not enough capacity on the ground for use and maintenance of these technologies (an area of particular interest for Mambi).
The paper also emphasizes the need for the technologies to be appropriate for the settings they are introduced in, which is where careful needs finding and innovation come in. The paper concludes, “Assessing medical needs, building capacity, and promoting cost-effective innovation will help in realizing technology's potential for achieving better health in low-resource settings.”

Compassion fatigue

Something else my ward team spoke about was “compassion fatigue” – both among practitioners and also relatives of those who were terminally ill. This was in reference to a case where an aunt brought in her nephew in his early teens. He was HIV positive (vertically transmitted), possibly had TB and had very aggressive KS. She had to travel a considerable distance to the hospital, and also had no money for tests or medications. Although she was obviously concerned about her nephew, she made it clear that if there were any costs associated with treatment, she would have to take him home (although it was clear he was severely ill). Another anecdote I heard from Dr Gugu Kabayadondo relates to "compassion fatigue" among health professionals - she was talking to one of the nurses in the wards who had been present during a severe train wreck a couple of years ago. The bodies were put in a vacated room and when relatives came in, the nurses had to go in and identify the individual sought. On one such trip, the nurse found someone who was actually alive and had been left in the room erroneously. She told Gugu that after that experience she needs to maintain a sort of detachment from her patient - she has seen too much to be otherwise and remain sane.

TBL in Practice - 5th year HIV curriculum

This Thursday was the first session of the HIV course for 5th year that will be using a lecture and team-based learning format (of faculty development workshop fame). Dr Gray and Dr Fana will be giving this course over a 10 week period, with each session 1 to 2 hours long. The plan is to have 5th year students take the course as they rotate through their medicine elective. After my week on the wards, it is even more clear to me than it was before that HIV is definitely a priority area, as so many of the patient cases are HIV-related.

The course objectives/ rationale, as per the curriculum are:
- To prepare 5th year medical student rotating through their 3 month medicine rotation to care for patients with HIV and TB.
- Zimbabwe is in need of new medical doctors that are prepared to address the needs of the country during the ongoing HIV epidemic.
- In accordance to the goals of the Medical Education Partnership Initiative, NECTAR program, and the University of Zimbabwe College of Health Sciences, this curriculum is intended to complement the established medical curriculum at the school to prepare graduating medical students to care for patients with HIV and TB.

As part of the NECTAR program, each student will receive a copy of the textbook American Association of HIV Medicine- Fundamentals of HIV Medicine (2007 Edition). There is assigned reading from these books each week (which makes sure that all the students have access to the same material for the preparation phase), and the sessions will commence with an individual test, followed by a group test, and then group exercises to build on the material for the given lecture day. I will be attending the first 5 lectures in the series of 10.
1. HIV epidemiology, transmission and prevention
2. Diagnosis and evaluation of a patient
3. Antiretroviral therapy
4. Treatment failure and HIV drug resistance
5. Complications of HIV - pulmonary
6. HIV-TB co-infection
7. Complications of HIV - neurology
8. Complications of HIV - gastroenterology
9. Complications of HIV - dermatology and STIs
10. Complications of HIV - hematologic complications and AIDS-associated malignancies

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The team voting phase, where the students discussed the answers, and as a team presented the group response. [in this case, the issue was with 1 of 4 answers not being practically feasible in Zim, so some students picked "all the above" as the answer, while others selected the best of the three options that were uncontestably correct]

The first lecture went well, and most of the discussion afterwards was about 'ideal' versus 'practical' treatments or prevention techniques - the answers to the questions on paper did not always tally with actual practice on the ground. Another sobering thought about HIV in Zimbabwe relates to the much-applauded reduction in prevalence. There are potentially two causes - reduced incidence due to greater awareness of prevention measures, and the second alternative of high death rates, particularly during the time when ARVs were in more limited supply.
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Students discussing questions while Drs Gray and Fana are at work in the background

At Vic Falls and Hwange

This weekend, I went to Hwange and Victoria Falls with the family. I had not been to either for a decade or so, and it was wonderful to be back. Aside from the incredible beauty and tranquility all round, it was also a treat to go back to the lodges we used to go to in my childhood, and find that many of the staff were still there, business was picking up again, and things were normalizing.

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Places worth visiting in Zim

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Shameless plug for Ganda lodge (near Hwange), part of the Forestry Commission group of lodges (there is another at Victoria Falls, called Jafuta lodge). This description from Quo Vadis:http://www.quovadis-southern-africa.co.za/content/12/3863/en/ganda-lodge-dete-western-zimbabwe-southern-africa.html
In the beautiful teak woodlands of the Sikumi Forest bordering on the Hwange National Park. Private 20000-Ha estate overlooking the Ganda Dam, a natural waterhole that attracts a variety of bird and animal species including elephant, buffalo, lion and a variety of waterfowl. Eight double storey thatched lodges, each with its own bathroom and shower. Teak furnishings and a private fireplace in each room. Main lodge includes a lounge with a well-stocked bar where visitors can relax and enjoy a sundowner. Excellent cuisine in the dining room. Retire to the boma to enjoy the splendours of an African night while watching animals at the floodlit pan. Transfers from Hwange Airport. Relax at the pool during the day watching the game as it comes down to the dam to drink. Game drives to see the Big5 in the company of professional guides. Night drives. Walking safaris to get close to nature. Tours of nearby African villages to gain an insight into rural African life and culture.

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A view of Ganda lodge. There are eight chalets, most with 4 bed each on a top and lower floor. The surrounding area is relatively "wild" - around 4am, hyena calls could be heard in the near trees, on two days, a lion walked through the camp in the early morning, and a week before, overzealous tourists had interrupted a buffalo kill (apparently, there are two prides that operate within that 20 000 hectare area, the Balabala pride, and the Dynamite boys (two males remain of the original four). The Balabala pride comprises seven lionesses and one lion - apparently, they had the buffalo immobilized and were waiting for the larger, heavier lion to latch on and force the buffalo to fall over, when the flash-lights startled them...) At the watering hole, elephants had their afternoon "powder room" and salt added to the water made them return daily (that, and winters being dry).

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A quaint little restaurant that we saw near Chegutu - now defunct. The idea was quite inspired, though --- it is called "The Flying Pot" and the restaurant is two aeroplane shells. No one around knew much about its history, though.

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Victoria Falls is all its glory (well, some of its glory, I am not the best of photographers). There were multiple views over a 1.6km stretch, with a double rainbow. Post-walk, one can go bungee jumping over the Vic Falls bridge (111m, I think); and also white-water rafting opportunities abound.

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Painted/ wild dog conservation. http://www.painteddog.org/
A few kilometers from Ganda lodge was the Painted Dog conservation site, built in the early 2000s, and working to rescue maimed animals, and also to generate greater community awareness about wild dogs (the organization refers to them as "painted dogs" to reduce stigmatization by the population, who would associate "wild" with dangerous rabid dogs. In general, painted dogs leave you alone if you are not impala or something akin..)

From the organization website: Painted Dogs, also known as African Wild Dogs, are unique to Africa and they are among this continent's most endangered species. It is estimated that a mere 3,000 - 5,000 remain. The Painted Dog population in Zimbwawe is one of the last strongholds of the species and we are committed to their conservation. Our conservation methods and our work with the local communities are beginning to have a positive effect on the outlook of the Painted Dog species.

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Close up view of lion kill in Hwange national park --- I was about 5 meters away from the lion when I took the picture.

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There were a lot of elephants! An adult elephant consumes 100-300kg per day. That certainly adds up! Another random fact - the gestation period is 22 months. Over the years, I have amassed a bit of wildlife trivia. I sometimes think I would like a life out in nature. Maybe.

"My dear, there's been a change of plan..."

Design thinking
The last few weeks have gone by in a (mostly) delightful blur. I am finally more attuned to the pace of things here. Now that the workshop activity has subsided, the next task is to keep everyone connected, and make sure that there is follow up on the design project. There is also the research component that is meant to come out of this pilot phase – Zaza, Mambi and I will be working with Mr Chingono and assailing the (thus far) impenetrable JREC fortress (JREC = Joint Parirenyatwa University of Zimbabwe College of Health Sciences Ethics Committee) to allow us to do learn about the utility of design thinking in a Zimbabwean context.

MEPI medical curriculum supplement
I also FINALLY navigated the bureaucratic tangles and got a green light to work on the medical curriculum supplementary material to be put on the UZCHS intranet by Stanford (and hope that my Stanford med friends are still keen on making this a reality). Six weeks seems like a long time, but my King's College colleagues' experience makes me think this is fairly standard - for the first round that is. They are confident that things will work faster when more of their students come in next year, and I am sure that will be the case for Stanford as well.

"Can you tell me more about that..."
Add to that my freshly printed “Elective Student welcome letter” giving me access to medicine wards for the next three weeks and ob-gyn for two weeks. I am quite curious about how much work will be needed for me to get up to speed with translation. Medical Shona is quite foreign to me.

Exit
After much deliberation, my advisors and I decided that an early truncation of my on-the ground Zim time for MEPI activities would be best. As I write, the NECTAR team is having a half day workshop to debrief on and discuss the activities of the past year (year end 31 August!) There has been a lot accomplished, but the program has a rather complicated logic model, numerous partners working together, and in the first year of such a large grant, aligning everything and making it fit together is difficult. I have great appreciation for the way this is being done – it is important to see where the pieces go, and how this will all strengthen the system in a sustainable manner.
When I arrived, I was super enthusiastic about getting the intranet on the ground, I spoke to anyone who would listen, and I wanted to get started yesterday (mostly because the Stanford group had been talking about getting this underway since October last year!) Talking more with Prof Hakim, Dr Barry, Dr Gray and the Colorado team was useful for figuring out what necessary groundwork should be done before populating this intranet – the needs finding that I was sent to do (and finally have permission to carry out!) The plan, then, will be to index the material we are sending in appropriately (to have a quick reference for the students, and make sure they actually use it!) Before that, though, will be extensive discussion with the first and second year instructors about which areas are a priority, and what materials they need. I am wildly ecstatic that this is finally happening.

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Stanford, Stanford... Back in October...

Re-entry
I have also been thinking about MY medical education, and how the projects here fit with my personal goals! With that in mind, over the next 6 weeks, I am putting together as many materials as possible for the Stanford working group activities over the next year or so, and returning to the place where “die Luft der Freiheit weht.” After my medicine and ob-gyn mini experiences here, I will re-inject myself into the Stanford system gently, with autopsy pathology clerkship in mid-October (to be more like my hero, the fictitious naturalist and eminent physician, Stephen Maturin, who loved dissecting…) It is odd to be truncating the current trip, but for the stage the grant is in, and where I am in my training, I think as much has been done this trip as is possible for me to accomplish for this year, with the additional months having diminishing returns.
In the meantime, my distraught parents have organized an “emergency vacation” before I disappear. Victoria Falls and Hwange this weekend – here I come!

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