Here is another
journal about some experiences and reflections of the clinic in Gabs. It picks
from several points throughout the semester. Enjoy!
Since my last journal about my
experiences in the Broadhurst 3 clinic, in Gaborone, I have learned many things.
On February 31st, I shadowed the ARV doctor. This was my first
experience of shadowing a doctor in Botswana. Since one of my main areas of
interests in the humanities is the ethical issues surrounding patient autonomy
and the doctor-patient relationship, I was excited to begin learning about this
in Botswana. The doctor I shadowed on this day was a quiet man from Ethiopia,
who gladly welcomed me into the consultation room. Most of the patients he saw
on this day were people who were returning to refill their ARV medication. The
basic procedure when this is done is as follows: the patient will come in 2 or
3 days prior to consultation, to have his or her blood drawn, then the patient
comes in to see the ARV doctor and review the current status of the disease.
The basic points of concern from the blood test are CD4 count and the viral
load. Mature helper-T cells express the CD4 membrane protein and are referred
to as CD4+ helper-T cells. The CD4 count measures the concentration
of mature helper-T cells present in the blood. The viral load measures the
amount of detectable HIV virus in the blood. Patients enter the consultation
room and hand the doctor their identification card and patient file, and the
doctor begins analyzing the blood test. If the patient is just beginning ARV
treatment the doctor will ask if they have any questions about the treatment.
At this point, the patient will have already undergone counseling, and the
doctor is simply following up to make sure everything is clear. If the patient
is returning for continued treatment, the doctor will explain the results and
discuss the status of the current disease.
My first
impression of this entire process was that it is very technically sound, but
personally detached. The doctor that I was shadowing on this day did not seem
to take any particular interest in the patient. Rather, he was immersed in the
test results, and very much focused on the numbers on the paper he was
interpreting. While this in itself is not a bad thing, in my opinion the separation
from the patient is a problem in the field of medicine. It is true that every
doctor (or provider) is an individual and will have a unique way of addressing
patients and handling daily duties. Still, the problem at hand is a real one,
at least for those who still hold the art of medicine—as compared to the
science—as valuable. The struggle to find the correct balance between the art
and science of medicine is one that is far from new and far from being
resolved. In the real world of practice, it can be extremely difficult for
patients to get the time and attention they deserve. A Cuban doctor we spoke to
in Serowe echoed this problem, describing a Cuban system that was almost facing
the same trouble at the other extreme. In Cuba doctors are penalized for
ordering too many negative tests. This forces doctors to be much more hands-on,
obtaining from the physical examination the most possible information. It has
been my conviction that the straying from the physical examination as the
primary tool of a doctor is one of the greatest problems in medicine. My
experience in Botswana has confirmed this as a threat not only to American
medicine, but also to medicine worldwide.
My next
experience in the clinic was with the general doctor. Here patients presented
with all sorts of different ailments, including: sexually transmitted
infection, tonsillitis, chronic hypertension, asthma, and skin irritations.
This is a pretty standard list, with not much difference of what one might see
in the U.S. I have found it interesting that hypertension and diabetes are
major health issues, in this country, since obesity does not seem to be one.
Interestingly, I was told that the diets here are very high in starch and
energy. I have noticed this as well in my own experiences. The main dish at
nearly every meal is overly large portions maize or sorghum based porridge,
which are exceedingly high in energy. On campus, the snack item of choice is a
fat cake. This is basically deep fat fried homemade bread, and is made in mass
quantities at every cafeteria.
In
addressing these problems, the doctor told me that he is required to process
each patient through quickly. He even mentioned that he has been warned by the
Ministry of Health for spending too much time on individual patients. As a
result, he was very quick in his work, and very quick to prescribe medication.
This is another major problem that I have noticed in every clinic I have been
to. Prescription of antibiotics and painkillers is given with alarming ease. If
a patient presents with an infection of any sort, antibiotics are prescribed
immediately. As is well known, the effectiveness of antibiotics is diminishing
quickly, in large part due to over prescription by providers. The doctors here
do not seem to recognize this, and do not even counsel patients on the vital
importance of adherence to these drugs. This doctor was also very quick to
refer patients when they seemed outside his ability to treat. For example, one
patient came in with an eye irritation, and without even being examined; the
patient was referred to another doctor, since the eye seemed to be an area
off-limits to this doctor. A similar situation arose many times, and I was
surprised that the doctor was so quick to move the patient along, without even
performing an examination. As mentioned, this is part of the requirement of his
job and is, unfortunately, an expected outcome of dealing with a heavy patient
load and minimal personnel.
Since
returning from our visit to the village of Serowe, I have visited the clinic
twice. The first time, I returned to the ARV doctor, to continue learning about
treatment of HIV/AIDS. The doctor on this day was from Zambia, and had a much
different personality from the first that I shadowed. Before, I assumed the
language barrier prevented the doctor from meeting the patient on a level
suitable for intimate discussion. The Zambian doctor I shadowed this time
around, however, was very sociable and managed to get the patients to open up
much more than before. He was able to understand when a patient was holding
back, and find the right words to make them open up to him. This gave me
confidence that while patients prefer to speak Setswana when discussing such
important things, many are still able to communicate effectively in English when
the doctor is able to take control of the conversation. This is especially true
in the city, Gaborone.
I also
gained many more insights into how ARV treatments are delivered. One young
woman came in who was fighting tuberculosis. When an HIV-positive patient is
also infected by TB, ARV treatment is started regardless of the CD4 count. This
means that the patient will have to remain on ARV treatments for the rest of
his or her life. This is especially unfortunate in a young person, since
treatment is not to be stopped once it has been started. Since there are only
two lines of treatment available, this increases the patient’s chances of
becoming resistant to both lines sooner. One of the main challenges of ARV
treatment is to make sure the first line of drugs lasts as long as possible.
Once the patient begins to resist these, treatment becomes exceedingly
difficult.
In many
cases the antibiotic cotrimoxazol (CTX) is given as a prophylaxis against
opportunistic infection along side the ARV treatment. However, this antibiotic
has many severe side affects and cannot be given to every patient. When it is
not given, the patient is at an increased risk of acquiring an opportunistic
infection. Prescription depends on the health of the liver, as determined in the
blood tests; as well as by the overall health of the patient. The ARV doctor
must account for both of these in discerning whether or not this antibiotic
ought to be prescribed.
I also
learned that the Ministry of Health would soon be increasing the CD4 count
required to receive ARV treatment. At the moment, the count is <200cells/uL,
the change will increase it to <350cell/uL. The positive side of this is
that patients will be able to start treatment before the HIV virus has begun to
attack the immune system so seriously that it is hard to recover. However, from
the perspective of the medical system, the patient load will be dramatically
increased, while the personnel numbers will struggle to keep up. In addition,
patients will begin treatment at a younger age, increasing the likelihood of
becoming resistant to the ARV medication.
Interestingly,
I asked this doctor to compare the medical system in Botswana to his experience
of the one in Zambia. He told me that when it comes to treatment of HIV,
Botswana is much more advanced. For example, in Zambia the viral load is not
even considered in ARV treatment determining how to organize the ARV regimen.
While praising the free system, he also warned that a host of problems also
follow with the system of free care in Botswana. Many of these have been
described in this short reflection.
My final
conversation with the ARV doctor was about the reasons for the success in
lowering the rate of new infections in Botswana. In addressing the culture, he
gave two things that have allowed the campaign to be successful. First was the
decrease in the taboo on talking about sex. He told me that patients today are
open to talking about issues revolving around sex. They now understand the
importance of these conversations, especially in the health field, and are
willing to do what is necessary for their health. Along these lines, patients are also much
better informed now. Since patients are better informed about the nature of HIV
and ARV treatment, they are better at taking necessary steps in their lives to
treat or avoid HIV. While this is not universal, the sentiment is beginning to
spread strongly throughout the country, and is allowing for the fight against
HIV/AIDS in the country to take a turn for the best.
My final
experience, thus far was with both the HIV-testing clinic and then again with
the general doctor. I arrived at the HIV-testing trailer in the morning, but
the line was not very long. I assisted in the testing of several patients
before the line dwindled. Even with all of our immersion in the problem of HIV
in Botswana, it is still startling to see someone find out for the first time
that he or she is positive. On this morning, I witnessed this happen to a man
from Zimbabwe. The man claims to be faithful to his wife, but does not use a
condom when sleeping with her. Unfortunately, since he is not a citizen of
Botswana, he is unable to receive free ARV treatment. The counselors rattled
off the practiced speech about finding a trustworthy person to discuss his situation
with, as well as the importance of urging the wife to be tested. While this man
was clearly surprised by the results, he was not very inquisitive; and beyond
simple questions, the counselors did not make a rigorous effort to really
understand and inform this patient, who had just been given life-altering
news.
Once the
testing clinic became stagnant, I moved to the general doctor. This doctor was
from Ethiopia, and had been trying to find a job in the U.S. for some time. He
has taken all of the required licensing tests, and has been attempting,
unsuccessfully, to obtain a hospital residency position. His reason for
desiring this was the opportunities that are opened up from having residency
training in the U.S. “You can practice anywhere in the world,” he told me.
Since my time with him was short, we did not
see many cases. One interesting case was a woman who showed signs of an STI.
The doctor told me that it could be caused by any of multiple organisms and,
without a lab test; it was impossible to identify the source. As a result, it
is necessary to prescribe several different antibiotics to fight several types
of infection. This returns me to my point made above about the over
prescription of antibiotics. The doctor did not seem to see any danger in
prescribing this many antibiotics to one patient.
My
experiences thus far in both Serowe and Gaborone have been invaluable. Through
these, I have come to a better understanding of healthcare in Botswana, as well
as how the HIV pandemic is being treated in one of its hottest spots in the
world. Learning about treatment and the nature of HIV in this country provides
a giant window into this disease, which has devastated countless people’s lives
all over the world in such a short period of time. Beyond this, I have also
been able to reflect on the nature of medicine, and my own desire to pursue a
career, and life in medicine. My conviction that this is the proper course for
me has never been stronger.
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