Experiences and Reflections from Serowe Healthcare

       
  There were eight students who traveled to Serowe to learn about the healthcare of Botswana in a village setting. We split up into 3 groups, each group assigned to a certain clinic in the village. I and two other students were assigned to Serowe clinic, which was a mere ten-minute walk from the neighborhood in which we were staying. We arrived at the clinic early Monday morning and were introduced to the head nurse. The nurse showed us around the clinic and then told us to allocate ourselves to different areas of the clinic. The three of us began by working in the child welfare clinic, which is run very similarly to the one in Gaborone. Mothers bring in their children up to five years of age to be weighed and to measure their heights. This is done each month and the results are recorded on a graph in the patient chart. The height and weight data is compared with each other; if a child is underweight, a third test is done to clarify the results. They use a tape-measure armband to measure the circumference of the upper arm. If the distance does not meet the marked ‘green-zone’ then the child is considered to be malnourished. In this situation the mother will be counseled on proper care of her child, and appropriate amounts of food will be distributed to the family.

Although English is the official language of the Botswana, it is not the first language of any of the locals. We faced the inevitable barrier in trying to inquire about the effectiveness of these tests. In the child welfare clinic height and weight are recorded in different charts and did not seem to be correlated. In addition, the confirmatory armband test did not have any dependency on the age of the child. From one month to five years the same band is used to confirm malnutrition, which seemed counterintuitive to us. When we asked the nurse about its effectiveness across this wide age range, she went on to explain to us how they check for malnutrition, a process we mostly understood at this point. Later in the week, we put the question to another doctor who explained to us that the height and weight are combined in diagnosing malnutrition in a child. The uncertainty of the armband, however, was an issue that was never resolved for us.

Mondays and Fridays are ARV (anti-retroviral) days in Serowe Clinic. On these days, patients come in to begin or continue ARV treatment. Patients also come for general consultation as well. There were two doctors seeing patients in the consultation rooms. In the afternoon I shadowed a young doctor named Paul. On this afternoon, Paul saw various cases including: HIV, cysts, various skin irritations, and possible tuberculosis. TB is an illness that has become a major issue in Botswana, and across most of the developing world, especially where HIV is prevalent. I asked the doctor if patients suspected of TB are ever asked to wear masks to protect the workers. He said they do not do this unless this patient has multi-drug resistant (MDR) TB. He explained that nearly everyone who works in health in Botswana would test positive for TB. Apprehension for my own health aside, this did not seem like the best public health policy. After all, MDR-TB is born out of non-MDR-TB and control of the latter should lead to control of the former; or at least reduce its proliferation. In addition, if health workers are not properly protecting themselves from TB, they also put at risk patients who are negative for TB; a risk multiplied in a nation that carries the second highest HIV prevalence in the world.

Working in the clinics has been an indispensably informative experience in learning about healthcare delivery in Botswana, however there has been a nagging tendency to get the idea that HIV is not as a big of a problem as it has been made out to be. In the clinics, patients have rarely reached a stage of the disease that is devastating, and most seem healthy. On our last day in Serowe, we were taken to the Sekgoma Hospital, to have our doubts stripped away. It was Friday, ARV day, and we walked in to an excessively bustling clinic. We pushed our way through the crowd of people surrounding the two consultation rooms, and made our way in to talk to one of the doctors. There was a new, more senior doctor in today to see patients. He told us that with the amount of people needing to be seen, he would not have time to talk to us about the patients, and didn’t feel that our experience with him on this day would be worthwhile. Instead, he called the hospital and arranged for us to shadow some doctors at Sekgoma. We caught a cab outside the clinic, and within minutes found ourselves in the accidents and emergencies ward, searching for the doctor. Upon fulfilling our search, the doctor showed us to the patient he was currently seeing: a man with Stevens Johnson syndrome, which is an allergic reaction to the sulfur-based ARV medication. This is a life-threatening skin condition in which cell death causes the dermis to separate from the epidermis. When we first saw the patient, I thought that he had been victim to a serious burn. However, the burns were found in patches all over his body. The doctor then explained to us the cause of this patient’s pain. After this, the doctor decided to take us to the general ward of the hospital. As we walked through the halls of this large hospital, the most noticeable feature of the building was its desolation. The halls were empty. However, when we reached our destination, we found a busy ward. We were introduced to a doctor from Cuba, who was seeing patients of all sorts of ailments. There were two cases, however, that have been fixed in my memory. The first was an HIV-positive patient suffering from cancer of the throat. We were allowed to view this for ourselves, and we saw a large tumor at base of the tongue of a young woman. The woman had come in due to complications, but was about to be released from the hospital. She was waiting on biopsy results to return from Gaborone, and the doctors could not operate until their arrival. We were informed that biopsy results could take up to 2 months to make it back to Sekgoma hospital in Serowe. The second patient we saw was a young woman in her mid-20s suffering from AIDS related wasting syndrome. The woman had failed to properly take her ARV medication, and the disease was now consuming her body. At home, she lived alone, and lacked any familial support in her burden. Now she was laying in the hospital bed at Sekgoma, staring blankly into the wall, as the doctor examined her and moved onto the next patient. This was our first true exposure to a patient whose life has been devastated by HIV, and she is not alone. Later in the pediatrics ward, we were shown a baby who had contracted HIV at birth, and now was suffering from TB and malnutrition. Botswana has implemented a very successful program called Preventing Mother-to-Child Transmission of HIV (PMTCT), which has greatly reduced the number of babies contracting HIV at birth. Unfortunately, however, not every mother follows the program, and the program itself is not 100% successful. On rare occasions, babies such as this one are unfortunate to contract the disease at birth. While the reduction of this has been a success for Public Health in Botswana, hopefully soon it will become a total victory.

Our experience at Sekgoma hospital has been the most invaluable one of our stay in Botswana thus far. Here, we were exposed to the true impact of HIV on the lives of people of Botswana. We also were able to talk to many different doctors about practicing in Botswana, and further explore the dynamics of the healthcare system and the relationship of doctor and patient in this country.

                                             
                                              (Note: all photos in this post taken by Dina Fico)

Weighing babies

The armband used to check for malnutrition 

Karata -- The patient's chart

The pharmacy

Reflections

In the clinic in Gaborone most patients speak English well, however many prefer to communicate in Setswana. This is because most patients are most comfortable expressing themselves in Setswana and are able to understand instructions from caregivers more accurately. Still, English is a viable option when caregivers are unable to speak Setswana, as is the case with most doctors in Botswana. However, in the Serowe clinic, very few patients spoke English. This is a major problem for the country, as most of the doctor positions are filled by expatriates. The main reason for this problem is the lack of a proper medical school in the country. As I mentioned before, the University of Botswana has recently created a medical school, however, it has yet to gain accreditation or respect in the medical field. Until the School of Medicine establishes itself, the government of Botswana will continue to send medical students abroad to receive education. Because of this, the vast majority of students fail to return to Botswana to practice.

           One of the most interesting things about shadowing healthcare workers on the ground is to hear the varying opinions about the system and its future. So much about the jobs of these workers is dependent on policies put in place by the government. This is not unique to Botswana either. I remember shadowing various doctors after the passage of the new Healthcare law in the U.S. last year. Opinions I received ranged anywhere from passionate enthusiasm to gloomy uncertainty about the future. Perhaps it is a testament to the nature of healthcare work that providers are able to continue their jobs effectively even in the face of so much uncertainty and confusion. It is well known that hospitals anywhere in the world are a hub for human suffering, and the attitudes of those who work in these places are undoubtedly affected and shaped by this fact. Then again, perhaps I am merely romanticizing the profession to which I plan to dedicate my life. Either way, these professionals all have serious opinions about the systems in which they work. In Serowe, I heard doctors and nurses cursing the system under which they work; complaining about lack of supplies and personnel. ‘Botswana is a disaster!’ One nurse said this to me speaking about the healthcare system of Botswana. On this particular day, no doctor had shown up to the clinic, so this nurse was put in charge of consultations for the day. This means she performs all the duties of a doctor, including prescription of drugs, with the exception of interpreting lab results. This particular nurse was very young and was only 6 months out of school. I asked if this was a common occurrence, and she explained that on her first day out of school, she was asked to perform consultations; answer: very common. Another doctor explained his discontent with the system after being unable to find examination gloves in the consultation room. In addition, the water supply to the clinic had been mysteriously halted, a problem, which was not resolved for several days. He told me that a major problem in Botswana is the allocation of funds within the system. ‘Those in the Ministry of Health who are creating policies are not doctors, they are politicians.’ This doctor was a Motswana, and although his consultations were mostly in Setswana, it was clear to me that he was able to relate to his patients much more effectively than other doctors I have shadowed. Unfortunately, his dismay with the system was enough for him to desire to practice in a different country. It was clear that these practitioners had serious quarrels with the system of care and were not simply venting frustration.

            Still, others we talked to were very confident in the system implemented in Botswana. There is no doubt that the delivery of free ARVs to citizens of Botswana has been extremely effective. When ARV treatment was initially discovered, treatment was virtually unavailable for the general population of Africa that had been the hardest hit in the world. This was due, in part, to monopolization by pharmaceutical companies, preventing affordable treatment to areas of greatest need. Today, the price of ARV treatment has been massively reduced, and the government of Botswana has managed to provide free treatment to every citizen in the country. This success has been an inspiration of hope to sub-Saharan Africa in the fight against the HIV pandemic. Unfortunately, many countries still do not have access to the life saving treatment that can dramatically extend and improve the quality of life for people suffering from HIV infection. Botswana, however, offers treatment to all citizens of its country, allowing those living with HIV to have a much-improved quality of life when compared to neighboring countries, such as Zimbabwe or Zambia. Dr. James Orbinski, former president of Médecins Sans Frontières (Doctors Without Borders), said in his 2008 book, “AIDS is a fully treatable disease – as treatable as diabetes. Yet today, worldwide, 30 million people have died of the disease, 33 million live with HIV infection, and upwards of 100 million may be infected by 2020.” There is no doubt that Botswana is at the forefront of the fight to make ARV treatment available to all areas afflicted by HIV/AIDS.

            When comparing healthcare in Serowe to that in Gaborone, the biggest noticeable difference is the lack of proper personnel in the clinics. The Gaborone clinic in which we have been involved with is actually very well staffed, and the organization of each ward runs smoothly together. Apart from this, many of the same problems with lack of supplies and barriers in communication are still felt.

            Hopefully you now have some idea of the various things I have been doing relating to healthcare, and of my experiences in Serowe. Many of the thoughts provided in these reflections are applicable both to Serowe and Gaborone. As the semester moves along, I am beginning to gain an understanding of the dynamics of the diseases around which the system of healthcare in this country are based. 

Children after a public health discussion on Safe Male Circumcision

Vaccinations at a school

The public health group