Double Jeopardy

Talk about double jeopardy.

Sadly, in this country, the rates of HIV and TB co-infection are among the highest in the world.

The vivid reality of that fact was recently brought home for us here at TTL, as we finally determined what has been plaguing Retsepile and hindering his health and recovery.

After being hooked up to life-saving fluids just two weeks ago, he had returned looking a bit better and we had begun feeding him plumpy nut, mixed with porridge to make it easier for him to digest, to continue to improve his weight and health. But like clockwork, he began vomiting and having diarrhea yet again, and his strength rapidly deteriorated once more.

Though we had started him on ARVs for his HIV and were working as diligently as we could to ensure his food intake was on target, there seemed to be an underlying problem that was preventing him from improving.

Under the suggestion of Dr. Chris from Baylor, we took Retsepile back to the hospital, where a chest X-ray finally read correctly showed signs of underlying TB.

Retsepile's ARVs were stopped, as they weren't doing him any good -- and were in fact weakening him -- with the underlying issue unaddressed, and we started him on the first phase of TB treatment.

After spending the required amount of time in the hospital letting the medicines take hold, Retsepile is now back at the safe-home.

He is emaciated. His limbs look like nothing more than twigs with skin draped over them. His face is gaunt. Still he smiles. Still he fights all that is against him. Still he pushes on.

He is now eating well and his vomiting and diarrhea have stopped.

I am crossing my fingers that we have finally nailed the problem on the head, and that Retsepile will at last begin to recover.

Visions

In the doorway of a rondaval in a remote village, I notice a knife blade with no handle that has been forgotten on the floor, left behind for the barefoot children of the house to hop over while coming and going.

I raise an eyebrow at what is meant to be the "road" to our next destination, then engage the 4-wheel-drive and proceed over boulders, across a stream and up slopes I fear might overturn the car, but that I know will get us to our next client.

In the next rondaval, I watch as our infant client crawls over her mother's chest, as the mother lays on an old mattress, bedridden with TB. I worry about the child's exposure, but nobody in the family seems concerned. A young chicken clucks around the room before dropping feces casually on the ground, near the blackened bucket the family uses for cooking.

I find myself haggling with a middle-aged Chinese shop owner, in a mix of English and Sesotho, over the return of money paid for baby formula that was never delivered. She eventually consents to my logic and forks over the cash. I consider this a lesson in business negotiation, and feel a sense of accomplishment.

I consider going to the bathroom in the TTL outhouse, even though the fierce seasonal wind has ripped the door off and shattered it into a half-dozen pieces, leaving the inside of the outhouse viewable from the street. I consider this because, just as the door was torn off, the town's water was shut off, making our toilet unusable. I think about all the other outhouses I've seen around town with no doors. I bide my time, mulling over the prospect. When the electricity shuts off, but the water comes back on, I consider it a fortuitous trade off.

I watch women on the side of the road meticulously butcher the carcass of a donkey -- for later consumption without regard to whatever it was that killed the donkey -- as toddlers sit nearby, amidst the foul stench, watching the whole, bloody ordeal.

I watch a man ride a horse across a dirt field in front of me, a small, baby-sized coffin on his lap.

I see a town so dry and windy that an everyday, panoramic, 360-degree horizon of mountain peaks becomes nothing but a wall of brown dust, blown as high as the clouds and making sky and earth indistinguishable from one another. In the dust cloud, nothing is clear but my immediate surroundings. I see rain finally come and people clap and sigh with relief.

My boss is away and I find the task falls on me to turn down two job applicants who I know are desperate for work. I try to do this with as much compassion as possible. I know we can't hire everyone, but I still feel mean. I also feel more like an adult than I ever have before, for reasons I don't fully comprehend.

Sitting in the playroom, I laugh when one of the bo'me comes in with a food tray, and the two toddlers in the room old enough to react start giggling, clapping and squealing with delight at the prospect of lunch time, patting their still-distended bellies with their tiny hands.

I go to the shop that supplies the town's weekly delivery of fresh fruits and vegetables, and dig through too-green and too-rotten bananas until I find a dozen that seem to meet my standards. I think back to the grocery store near my home in the U.S., and the towers of perfect, huge, bright-yellow bananas. Somehow, the dozen I find here seem superior.

I fly through two books in one weekend, enjoy them both, and wonder when the last time that happened was.

I climb a ladder to change an outdoor lightbulb. The task is simple, uncomplicated by human fragility, ego, sadness. It's easy. It's relaxing.

I repeatedly go over medical instructions for the hospitalization of one of the safe-home babies with a visiting doctor, asking him questions about signs of extra-pulmonary TB, chest X-rays, ARV regimens, anemia, mixing plumpy nut with porridge, antibiotic dosing and nasogastric tubes. Then I wonder if I will have to finagle a bed for the client at the hospital, or if one will be available.

I read about philanthropic decisions made for reasons like "cost-per-beneficiary," and scowl.

I finally win over a baby after a few weeks of effort, and she finally trusts me, even in the morning when she's cranky, and when I first realize it I get excited. Then, when I realize my excitement, I blush a bit.

I realize I'm doing and feeling and seeing lots of things, but still what I care about most is the approval of a two year old.

Little Ones Back Home

Two months ago, on Aug. 11, one-day-old Nkamoheleng arrived in TTL's care.

Her 18-year-old mother had died during delivery in the family's remote rondaval. Nkamoheleng had consumed nothing but small amounts of water since her birth. She was 2.4 kg, or just about 5.3 pounds.

Today, Nkamoheleng went home to live with her grandmother. She looks healthy and coos gently. Her pretty round face glows. She is now 5.1 kg, or more than 11 pounds. She is a wonderful example of TTL's strength in care -- even for babies so very young.

When I first wrote about Nkamoheleng coming to TTL, I wrote that, "In so many ways, the immensity of need here in Mokhotlong is wrapped up in Nkamoheleng's story," and hoped that "the rhythm of TTL success will soon resound there as well."

Now, two months later, it resounds quite loudly.

In addition to Nkamoheleng, little Refiloe went home today as well.

Refiloe arrived here one month ago, on Sept. 10, after her mother sadly died in delivery as well -- a too common occurrence in this country.

Refiloe will go to her maternal grandmother, still small at 2.65 kg, or about 5.9 pounds, but healthy enough to live with her family with the support of TTL outreach.

The departure of the two young girls leaves us with six babies in the safe-home.

Paballo and Boraki are starting to move around independently more and more, which is fun to watch.

Retsepile, after being so ill in the hospital so recently, is doing better but is still not out of the woods. His condition is so severe that he won't be for a while.

Still, he is smiling often and is much more engaged in general.

Dr. Chris, of the Baylor International Pediatric AIDS Initiative, came by today and saw Retsepile, as well as Nthabiseng, who has a cough, and Mpho, who still has skin problems. He tweaked all of their treatments and care plans, which I'm confident will help.

As for Nkamoheleng and Refiloe, now that TTL has helped them through the tragic start to their young lives, I hope they will thrive.

Visiting Old Friends

Today was a long day of driving far out into the rural Mokhotlong mountains, hours away from TTL, to visit with some old friends.

Namely, Seithati, Ntseliseng and Karabo -- three former residents of the TTL safe-home and three of the babies who I have become closest with in my time here.

When we got to the Linakaneng Clinic, Matello, our outreach coordinator, and I headed inside.

The first face I saw was Karabo's, who just left TTL about a week ago.

She recognized me at once and smiled big, sticking her arms out. I said hello to her mother, who I know well, and picked Karabo up. She laughed and gave me a "high five." The other women in the clinic laughed themselves and talked quickly to each other in amused tones, and I could tell they were amazed by the clear relationship between Karabo and me. I just smiled, and handed Karabo back to her mother as Matello and I began talking with the clinic nurses about a variety of issues -- among them a shortage of Kaletra, an ARV medication for HIV that one of our clients at the clinic is on and needs more of soon.

After a few minutes I walked outside, and standing there by the door was Seithati -- my all-time favorite TTL baby. I'd been there when we'd found her almost 8 months ago, and had seen her go from a shy malnourished child to an out-going, brilliant, healthy, rambunctious toddler at TTL.

Now, I recognized her at once, said her full name out loud in surprise and laughed, and she smiled up at me sheepishly.

"Ay, Ntate," she said.

I could tell she recognized me, but she was back to her old shy self, despite still looking relatively healthy.

"Come here," I said in Sesotho after kneeling down, and she walked over to me. I picked her up, and she wrapped her small fingers around one of my own, just as she always used to do. It sounds sappy, but my heart melted.

"Ho jwang?" I asked her. "How is it?"

"Ho sharp," she said. "It's good."

I laughed and put her down. She looked up at me with curious eyes.

She continued to take everything in as Matello and I weighed and measured all of our baby clients, some of whom I didn't know, and gave out some food provisions.

Seeing Seithati again was a great experience, despite our finding out that she has a cough that has been lingering for a while. I hope as the weather continues to improve, she'll get over it.

After the clinic, Matello and I headed off again, further out along the ever-deteriorating road, until we reached a designated meeting spot with another client.

There was Ntseliseng, being carried up the hill by her aunt, who had claimed Ntseliseng at TTL while I was in the U.S. at the beginning of September.

I jumped out of the car and said, "Hey uena, Ntseliseng!" -- "Hey you, Ntseliseng!"

Always the expressive one, though she still doesn't talk, Ntseliseng raised her eyebrows and smiled wide, showing her surprise at seeing me. Her face was as animated and telling as an adult's, and it got a big laugh out of me. She laughed too.

I was happy she remembered me, and went over to her. Her aunt untied the blanket that was holding Ntseliseng on her back, and I scooped my old buddy into my arms. She smiled.

We went into a nearby home -- the owner of which had pleasant experiences with TTL in the past -- and weighed and measured Ntseliseng. She was so scared of the process she peed on the scale, which I ignored as I scooped her back up before taking the scale outside to dry off. She had the signs of a rash -- which thankfully had already started clearing up -- but overall she looked good.

After saying our goodbyes, Matello and I took the long road home.

As I drove, I marveled at the strength of my feelings for the three little girls. They may soon forget me, I know, but I won't forget them.

Painted Black & White

I tapped the brakes quickly and slowed the truck as it curved along the black line of pavement, snaking through the mountainside villages and overlooking the lowlands below.

A group of five adolescent boys crossed the roadway a few dozen yards ahead, almost in slow motion, their stark white eyes staring back at me from their painted faces -- a charcoal, midnight black, covering their arms and chests as well. They wore some sort of brown animal hide or dirty sheepskin skirts, and each carried over one shoulder an enormous, charred-black log.

"What was that?" I asked Nthabeleng as we zoomed past on our way to Maseru, and they appeared smaller and smaller in my rearview mirror.

"They are going for circumcision," she said.

"Whoah," I said.

I'd heard about the "initiation schools" that young teenage boys go through here, where they are taken to the middle of nowhere, circumcised and "turned into men." But seeing the ritualized preparations of the process, the boys in what seemed a trance-like state, was another thing entirely.

"Why are they painted black?" I asked.

"I don't know," Nthabeleng said.

A few hours later, we sat in the new mall that was built in Maseru at the end of last year. There are escalators and shining storefronts and nice bathrooms and even a movie theater. It's like nothing else in the entire country.

In other words, I was drinking a cappuccino.

I thought about the vast difference between this world and the world of the initiation schools.

Then, up the escalator in front of us, came a handful of students in uniforms. Then another handful. Then a whole chattering school of them, wide-eyed and nervous.

"Are they on a field trip here?" I asked.

"Yeah," Nthabeleng said. "They want to teach them, "What is a mall?," "What is a lift?"

In all, we saw about half-a-dozen school groups at the mall. I thought of young American kids barking at their mothers for Cinnabunns and ridiculously priced clothing at malls in the U.S., and smiled at the eager excitement of these Basotho kids -- buying nothing, but enjoying it nonetheless.

The next day, Nthabeleng and I were again driving through the countryside, this time on our way back to Mokhotlong, when I noticed a gathering of people in a field to the side of the road. At the center of the gathering were a handful of young teenage girls -- dressed only in grass skirts, painted white from the waist up, and dancing.

"What was that?" I asked Nthabeleng again.

"Female circumcision," she said.

"They do that here?" I said, surprised.

"Yes," she said.

I sat with a far more intense feeling of pity for the girls than I'd had for the boys, thinking back to the mall and wondering what sort of connection my mind was trying to make between the two rituals and the new mall.

Then it came to me, painted black and white.

Nowhere else have I seen such stark examples of modernity and ritual, in such close proximity.

They were each, unto themselves, indicators of the upheaval I see occurring in Lesotho.

Many people in this country still live like they did thousands of years ago. Others live entirely modern lives. And in the transition of the population from the former to the latter, there is generational chaos.

Quite often since I've been here, TTL outreach has found a baby in terrible condition, cared for by a grandmother without the means or knowledge to provide proper nutrition, and left behind by a mother who "disappeared" one day in search of a better life in Maseru.

I wonder how long the people here will continue living in remote villages, or even in towns like Mokhotlong, before the desire to meet the modern world overpowers their devotion to family, to history, to the past. I wonder if they would be better off if they abandoned their simple lives in the mountains. I wonder how much of their suffering is directly linked to HIV, and if they would be otherwise content to live another thousand years in the mountains, if only they had their health.

I can't quite grasp the complexity of this moment-in-time for Lesotho. All I know is that babies are getting caught in the crossfire, and too many middle-aged people are dead from AIDS to stem the tide of consequences.