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.
