On Botswana

My first day in the pediatric cancer ward in Botswana was striking.  We have two rooms with multiple oncology patients in each room.  One room is designed for 6, the other is designed for 4; however, if there are not enough beds, then mattresses are flung on the floor wherever there’s a spot.  (So I suppose the true capacity of the rooms is the surface area of the floor divided by the surface area of a mattress…).  There are no labels to the beds, nor bracelets for patient ID, there are only names and landmarks (e.g. “Namueli under the Garfield poster”). The most striking aspect, I think, are the flies.  There are flies everywhere.  They crawl on the floors, they chill on the beds, and they land on the kids, even the cancer kids who are immunosuppressed! 

As this description of the unit illustrates, medicine is very, very different here in Botswana.  Resource availability, workflow, cultural practices, social interactions are all radically divergent from where and how I was trained. I find that these differences make the workday quite difficult. Cancer care is extremely complex.  Adequate resources are essential and the system needs to operate smoothly in order for treatment to proceed.  The deficiencies in the system tend to inhibit the progress of care. 

……

I feel that many times when I hear or talk about international medical missions, this is the kind of description I end up with - a laundry list of all the ways the system is not what we think it should be.  Yet while the difficulties here are many, our group is nevertheless providing ever-improving, high-quality care to the kids in our program.  We can do such good work because Botswana is an incredible country to work in.  It is true there are many difficulties to working here, but by developing a deep understanding of these difficulties, they can be overcome.  More importantly, we need to acknowledge that Botswana has many unique assets, which can be leveraged to unlock its potential.  To better understand healthcare delivery in Botswana, I want to go beyond the laundry list of complaints and explore its difficulties and its assets with the nuance and dignity that the country deserves.       

The Difficulties

            To discuss the difficulties of care let's use the example of the flies.  At first it seems ridiculous that there are flies in the hospital!  They pour in through the open windows in the unit. They are diarrhea vectors from hell and they all need to die a horrible death. It is frustrating to see them swarming the kids who have already been through so much.  Yet they persist in the unit because getting rid of them defies easy answers. 

Easy answer 1: Close the !@#$ windows!

            Nope: You’ll give the kids tuberculosis and you definitely don’t want to do that.  Botswana has one of the highest rates of TB per capita in the world at about 5 per 1000 people (http://www.aho.afro.who.int/profiles_information/index.php/Botswana:Analytical_summary_-_Tuberculosis) and all of those people love coming into the hospital to share the joy.  The hospital does not have any sort of central air conditioning and people are much more likely to contract it in enclosed environments with stagnant air.   So opening the windows and doors is the WHO-sanctioned poor-man’s version of environmental control (http://www.who.int/tb/publications/2006/tbhiv_infectioncontrol_addendum.pdf).  So easy answer 1 ended up with a bunch of tuberculosis infected cancer kids.  Go us.

Easy Answer 2: Buy air conditioning!  Then close the !@#$ windows!

            Nope: Are you kidding? The climate in Botswana is quite temperate most of the year, except for the very hot (but not humid!) summers, which can be relieved with fans. So most of the time central heating and air conditioning is a waste of money.  The hospital can do far more good for the patients by taking the money they would spend on air condition and instead buying vital supplies like antibiotics and chemotherapy.  AC is an incredible expense that outweighs the value of banishing the flies.  (At least we didn’t give the kids TB with this answer)

Easy Answer 3: Buy screens for the windows!

            Nope: Well actually, that’s not a terrible idea.  Except its already been tried and failed.  There are screens scattered on a few random windows throughout the unit, which is evidence of a past attempt at fly control.  I think the problem was that the windows were designed really terribly and it is very hard to open them with the screens on them, not impossible mind you, just more difficult.  The difficulty made people haphazard with how they handled the screens so they fell off over time.  It seems no one really cared to maintain them and put them back up.  This issue spirals into a really interesting discussion of organizational practices that perpetuate inefficient processes, for example facilities upkeep. I will not indulge in the discussion here, but suffice it to say we’ve identified a larger organizational deficiency of maintenance that neither I nor you are in a position to address at this particular moment.  So not a bad thought (by that I mean I don’t really have anything sarcastic to say it), but been there, done that. 

Easy Answer 4: Put up flytraps!

            No…Actually maybe: As it happens, I’ve made my own and am trying that as we speak.  I made homemade traps using coke bottles and sugar dissolved in water as an attractant (Youtube says it should work).  I have my reservations as to the efficacy of these contraptions, mainly because I’m not sure my sugar water is going to be attractive enough.  Flies seem to really like moldy fruit, rotting meat, or poop – none of which the hospital administration felt comfortable allowing me to hang in the rooms.  They also aren’t keen on using other types of chemicals or pesticides for understandable reasons. So sugar water it is! (If anyone has any other suggestions, I'd love to hear them...) 

This analysis illustrates that many seemingly simple problems defy easy answers.  Granted, I’m experimenting with an easy answer right now, but I don’t have much confidence I will be successful.  The larger point is that the roots of many of the problems extend far into the larger structures of the organization where no one person can reach them.  These structures include the actual infrastructure of the facilities, the resources available to us, the organizational practices of communication, the workflow of laboratory tests and other processes, and longstanding cultural practices.  This list is certainly not unique to this hospital, I could tell exactly the same story (and probably worse ones) at any hospital in the United States. The point is that this list helps to identify the relevant domains that need to be engaged if we are to improve the quality of care we provide.  Building health systems defies easy answers.  Our analyses of systemic deficiencies have to be as complex and nuanced as the system that created them.

The Assets

            Botswana is a magnificent country with incredible prospects for continued development.  To truly provide high quality care in international settings, we have to understand and leverage the strengths of the system. To identity its specific assets, a nuanced and complex understanding of the historical, social and environmental milieu is essential.

            Botswana was a British colony until independence of 1966.  It is completely landlocked and has very few natural resources except for diamonds discovered shortly after independence.  At independence it was extremely poor with a gross domestic product (GDP) per capita of about $70 per year.  Over the next 35 years, Botswana would clock one of the fastest economic growth rates in the world at 7.7% peryear from 1966-99, which is phenomenal when compared to other “economic success stories” over the same period such as Hong Kong at 4.6% and Singapore at 6.2%.  As a result of this growth, Botswana is considered an upper-middle income country by the World Bank and boasts a GDP per capita of  $7315.   Researchers attribute this economic success to lack of interference from post-colonial powers such as Britain, strong democratic government institutions, the consistent enforcement of property rights, and political leaders that made reasonable economic decisions.  A striking result of this success has been the country’s stability.  It has never had a major war even though almost every other country in southern Africa has experience exceedingly violent conflicts – Angola, Zimbabwe, South Africa, Namibia, Mozambique, DRC, Tanzania… the list goes on.

            This historical backdrop reveals many advantages that Botswana has when considering how to provide complex healthcare in this setting.  Its British roots made English one of the official languages of the country.  Its economic growth means that resources are more available than in many poorer countries.  Its strong government has provided a strong social safety net.  All people have access to health care either through paying for private-insurance or free government insurance.  Its lack of conflict means the population has avoided the catastrophic physical and mental consequences of war, allowing it to focus its priorities on expanding rather than rebuilding the health system. 

            Each of these assets can be leveraged to continue improving the healthcare system.  For example suppose we want to better educate nurses about caring for oncology patients. The task will be much easier, and therefore more feasible and impactful, because English is the common language in the hospital.  If we wanted to establish an outreach oncology clinic in a village 10 hours from the main hospital, that might be a feasible undertaking given the strength of the national health infrastructure and the presence of other outreach clinics already in the region.  Suppose want to work with the government to increase funding for cancer patients.  If there were warring factions vying for power or if corruption was too high, such discussions would be all but impossible.  These are just a few examples of Botswana’s assets at work. 

            Botswana’s most important asset of all is its people.  The people I have encountered here are beautiful.  There is a strong sense of community that is very evident in the hospital.  Mother’s are almost uniformly at the bedside 24/7.  When the odd kid comes in who’s parents are unable to accompany him, the rest of the mothers in the unit care for him as their own, even making sure baths are taken and clean pairs of clothes are available. Cancer care is a very long and grueling process, especially when you have to travel for 2 days every month to make it to the hospital, but families consistently make the journey and complete therapy (it is not unusual for many families to abandon therapy in the middle of it in many developing countries).   My Botswana co-workers are intelligent and hard working and represent a very promising future for the healthcare system.  The people I encounter in the town are uniformly friendly and willing to help out when I look hopelessly lost.  I’ve never once felt unsafe or any hint of aggression while walking through the city streets.  I’ve even noticed the men do not ogle at women nor make catcalls, but are rather respectful around them, which is a big deal if I ever returned with a family.  I don’t think I could honestly boast of this collection of social capital about any other developing (nor most developed) countries I have visited. 

            Basically, Botswana is amazing.  Its healthcare system certainly has its deficiencies, but all healthcare systems do, rich or poor. To address these deficiencies we need to honestly assess the system and avoid easy answers. More importantly, Botswana’s assets are exceptional.  With a rich history, impressive economic growth, sturdy social institutions, and lovely people that form the foundation of a strong society, Botswana is a success story that many people have never head of.  These attributes allow us from America to partner together with the people of Botswana to deliver high-quality cancer care to kids across the country.