Global Health Programs
International Medicine
Elective: Botswana
Welcome
Greetings Are Very Important
► “Dumela
Rra”
► “Dumela Rra”
 (Would be Dumela Mma
if a woman)
► “Le
Kae”
 How are you?
► “Re
Teng”
 We are well. (Use of
plural shows respect.)
Partnership Overview
Botswana-UPenn Partnership Mission
To help build capacity in:
Clinical Care
Education
Research
To offer opportunities in
global health for
Penn/CHOP trainees and
faculty
Botswana:
 Population 1.8 million
 Democratic
 Safe
 Dessert
Penn Compact
► The
Penn Compact seeks to propel the
University of Pennsylvania from excellence
to eminence in teaching, research, and
service through:
 increasing access
 integrating knowledge
 and engaging locally and globally
► Penn’s
presence in Botswana is a model for
Penn’s future global engagement initiatives.
Botswana-UPenn Partnership History
► Penn
has been in Botswana since 2001.
► First invited by ACHAP to have Penn
physicians assist in training local providers
on the management of HIV infected
patients.
 ARVS had just been made available at lower
cost in Africa.
 Botswana has national healthcare, but did not
have enough qualified providers to implement
treatment.
Botswana-UPenn Partnership in 2009
4 Major Initiatives in Botswana
1. Clinical care: HIV, TB, Women’s Health. ~ 55 fulltime BUP
employees in Botswana, including 15 doctors and
researchers
2. Education in collaboration with new UB School of
Medicine: Helped design internship and internal medicine
residency curriculum, planning med library in new
building
3. Global health opportunities for SOM Penn trainees: ~ 35
4th year med students and ~ 25 residents/fellows annually
4. Research
Global Health Opportunities for Penn Medicine
Trainees & Faculty
Med Students:
 Penn 4th year medical students go for 8 week electives
(36/yr)
► Residents and Fellows:
 Internal medicine residents (20/yr)
 Pediatrics, Dermatology, Radiology, Neurology, ID, ER
(~40/yr)
►
► Faculty: ~ 6-12/yr
► Integrated services:
We try to have interns and
medical officers from Botswana work with Penn
trainees and faculty.
► UB enrolled first class of medical students in August
2009 so soon, Penn medical students will work sideby-side with UB medical students.
UB-Penn Collaborations
►
Penn and UB collaborate on undergraduate and graduate
educational programs:




►
Semester abroad (bilateral)
Summer internships
Sabbaticals (UB at Penn)
HIV research (collaborative)
Penn helping to develop curriculum for Internship and
Internal Medicine residency in the new UB medical
school
Other American Universities Working
in Botswana
► Harvard
 Botswana–Harvard School of Public Health AIDS
Initiative for HIV Research and Education (BHP)
► Baylor
 Baylor International Pediatric AIDS Initiative
(BIPAI)
► University
 I-TECH
► Vanderbilt
of Washington
Sharing the expertise of a world-class
university with our partners in Botswana to
build capacity and excellence in clinical
care, education, and research.
Botswana
►
►
►
►
►
Land-locked country
Size of Texas / France
The Tropic of Capricorn
runs through it.
Kalahari Desert occupies
87% of the territory.
Also home to the only
inland delta in the world,
the Okavango.
Climate
► Semiarid
► Cool
winters (June-August)
 Average daily temps of 41 – 66F (but can be
colder at night)
► Hot
summers (December-February)
 Average daily temps of 71 - 91F (but can be
hotter and most buildings to not have AC)
► Rainy
season during their summer has
intense rain and thunderstorms.
People
60% of countries’ population belongs to one of
8 Tswana tribes (‘Ba’ means ‘people of’)
 Barolong, Bakwena, Bangwaketse, Balete,
Bakgatla, Batlokwa, Bangwato and
Batawana
Major Ethnic Groups
► Tswana
► Kalanga (11%)
► Basarwa / San / “Bushmen” (3%)
► Other Newer Groups (7%)
 Herero
►
Bantu group originally from Namibia fled to
Botswana in 1904
 Kgalagadi
 White
►
Penn
Religion
►
►
►
►
70% are Christian
7% have indigenous
beliefs
20% have no religion
Many Batswana mix some
African Traditional
Religious or Badimo beliefs
into their religious
practices (e.g. consulting
medicine men for advice).
Language
► English
is the official language.
► Setswana is the national language.
 It is used by the very young and the very old.
 G is nearly always pronounced as H and TH as T and E
is rarely silent.
► Gaborone
pronounced “Ha-bor-ron-ee”
 The people of Botswana are called “Batswana.”
 One person from Botswana is called a “Motswana.”
► Other
languages include Khoisan languages (“click
languages” of the San and Kalanga in the north)
Political History
►
►
►
British colony known as
the Bechuanaland
Protectorate (1885-1966).
Obtained independence in
1966.
Longest continuous
multiparty democracy in
Africa with 4
democratically elected
presidents:




Seretse Khama
Ketumile Masire
Festus Mogae
Ian Khama
1966
► Botswana
ranked as one of the world’s
poorest countries with per capita income
of $70 USD
► There
was only one 12 km paved road in
the entire country at the time of
independence.
Diamonds
► In
1967, diamonds were
discovered in Orapa
► Debswana, largest mining
company, 50% owned by
the government and 50%
owned by DeBeers,
generates half of all
government revenues.
(These are NOT “blood
diamonds.)
Current Economy
►
Mining: Diamonds, copper, nickel, coal, methane gas
 Diamond mining accounts for >1/3 of the GDP and 75% of export
earnings.
 Jwaneng diamond mine is the richest diamond mine in the world
►
Tourism
 Tsodilo Hills (UNESCO World Heritage Site), Chobe elephants,
Okavango Delta, Kalahari Desert
 Large nature preserves & good conservation practices
 Expensive park admission fees geared towards high-end tourism
 Big game hunting on private reserves
►
►
Cattle / Beef
Financial services
Growth
► Botswana
has had one of the fastest growth
rates in per capita income in the world.
► Per-capita income was $5,680 USD in 2007,
the highest among non-oil-exporting African
countries.
► Life expectancy soared from 49 at the time
of independence (1966) to about 70 by mid1990s.
A Great Success
► According
to Transparency Int’l, Botswana is
Africa’s least corrupt country
► Botswana has steadily employed a sound
fiscal policy
► National education
► National healthcare
But…
► Large
► High
gap between rich and poor
unemployment
► Women
head half of households
► Mining
hit hard by worldwide economic
downturn
► HIV
/ AIDS
HIV & TB
HIV Epidemic
UNAIDS Global Report 2008
HIV Epidemic: Sub-Saharan Africa
HIV / AIDS in Botswana, 2007
►
►
►
►
►
►
Second highest HIV infection rate in the world (after
Swaziland)
Adult prevalence (age 15-49 yrs): 24%
Infant mortality increased to 45 deaths/1,000 live births
People living with HIV: 300,000
 Adults (age 15yr and older): 280,000
 Women (age 15yr and older): 170,000
 Children (age 0-14yr) living with HIV: 15,000
Deaths due to AIDS: 11,000
Orphans (age 0-17yr) due to AIDS: 95,000
2008 UNAIDS Report on Global AIDS Epidemic
Batswana Life Expectancy
► 49
yo (1966)
► 70
yo (mid 1990s)
► 48
yo (2005)
Why is HIV / AIDS so Prevalent?
►
Concurrent Partnerships
 Average number of lifetime sexual partners in Botswana is lower
than in the US but Batswana are far more likely to have
concurrent sexual partners
 Some long-term girlfriends, “little house” mistresses
►
Highly Mobile Society
 Husbands and wives living and working apart (mining, cattle,
tourism) people go where the work is
 With mining and migration of labor, HIV spread from girlfriends
or prostitutes to wives
►
►
Lack of Male Circumcision
Income Inequality & Gender Dynamics
► People
who want children do not wear
condoms.
► Family is an important part of Batswana
culture.
► Children have historically signified wealth
and were insurance for old age.
► Women who are mothers have higher
stature in Botswana society.
Botswana’s Response to HIV
► Government
mandate to have no
new infections by 2016
► Free ARVs to all Botswana Citizens
► Prevention campaigns to address
cultural issues and stigma of HIV
► Free formula for HIV exposed infants
► Health care capacity and
infrastructure building
► International financial and technical
assistance
HIV / AIDS – Some Success
► 32%
of pregnant females were HIV positive as of
2006 (sentinel surveillance) down from 38% in
2003
► 90% of citizens eligible for ARV therapy are on
treatment
► Prevention of Mother to Child Transmission: 40%
down to 6%
Tuberculosis in Botswana
► One
of the highest TB notification rates in the
world
► Total number of new TB cases rose from:
 5655 in 1995
 10,228 in 2005
► Proportion
of TB patients who are co-infected with
HIV in Botswana ranges from 60-86%
► TB responsible for 13% of adult deaths and 40%
of deaths among people living with HIV/AIDS
Your Clinical Rotation
Botswana: What you See
►
Tuberculosis
 Extrapulmonary
►
►
►
►
►
►
Cryptococcal meningitis
Pyogenic meningitis
Pneumonia/lung abscess
Empyema
Diarrhea
Hepatitis
Rheumatic heart disease
CHF
► Malignant hypertension
► DKA
► Renal failure
► Multiple malignancies
► Anemia
► COPD( mines)/asthma
► Hepatic disorders
► Neurological disorders
► Dermatological disorders
► Seizures
►
►
Botswana: What you See
► More
unusual
diagnoses








Tetanus
Pellagra
Cobra Bite
Scorpion sting
Malaria
Cysticercosis
Cardiac tamponade
Unusual drug overdoses
► Procedures







Lumbar puncture
Thorocentesis
Paracentesis
Pericardiocentesis
Bone marrow
Chest tube
Peritoneal dialysis
Botswana: Living Conditions
► In
Gaborone
 Fully furnished flats
 Pretty cushy – flats have maids that do laundry and
clean, swimming pool…you won’t be sleeping in a hut
with a dirt floor (although these exist in Botswana)
 Walking distance to the hospital (NOTE – Students &
residents are prohibited from driving in Botswana.)
 Communal living and learning
 Low cost of living (groceries and entertainment about
half the cost of Philadelphia)
 Plenty of activities in Gaborone: Gyms, Restaurants,
Malls, Movies, University of Botswana, Soccer Games at
National Stadium, etc.
Botswana: Finances
►
We pay for:
► Plane
fare to Gaborone and back
► Flats / Housing while in Botswana
►
You pay for:
► Food
► Entertainment
► Recreational travel
 Plan for either before or after after rotation…students are expected to
work fulltime during rotation
 Travel is usually expensive
 Vacations people plan: Camping in Kalahari, safari in Okavango Delta,
Chobe, Tuli Block; visits to Victoria Falls, Namibia, Cape Town
► Travelers
►
insurance (highly recommended)
We have full-time faculty and administrators in country to
help with orientation and problem solving.
Botswana: Who Thrives
► Personal
at PMH:




characteristics for a successful experience
Ability to handle inefficiency and frustration
Willingness to pitch in and do “scut” as part of a team
Flexible with ability to improvise
Ability to focus on what you can accomplish in an
environment with limited resources rather than lament
what can’t be done
► Diagnoses
are often not confirmed
► Patients die of things that they would not die of in the US
Botswana: Who Thrives
►
Personal characteristics for a successful experience in
Botswana:
 Common sense and street smarts
► Need
to be willing to negotiate market prices and missed flights, and
thwart would-be pickpockets.
 Adventurous spirit and curiosity
► If
the idea of killing a roach with your flip-flop, or watching others eat
caterpillars (a delicacy in Botswana) horrifies you, this may not be the
best fit.
 Friendly and easy-going
► If
you can’t imagine a day without Starbucks, or sharing a bathroom
with 7 other people, this might not be a good fit.
 Respectful
► Batswana
value respect for elders and superiors, and successful
students learn how to follow local conventions.
Rotation Responsibilities
► Work
as part of team!
 Your role may vary according to the dynamics of
your team
► Clinical
care
 PMH wards M-F 7:30am-5pm
► Education
► Professionalism:
respect for colleagues,
staff, patients and family
Rotation Goals: Patient Care and
Medical Knowledge
► Patient
Care
 Understand management of common medical
complaints presenting in Botswana
 Basic diagnosis, care and management of HIV
 Provide care that is appropriate, compassionate and
effective
► Medical
Knowledge
 Enhance HIV and infectious disease knowledge
base
 Attend teaching rounds, conferences and
discussions hosted by PMH
Rotation Goals: Communication and
Professionalism
► Work
effectively with a patient care team
► Effective communication with patients,
family, staff and team
► Carry out ALL expected duties
► Demonstrate altruism and respect
► Adhere to ethical principals
Rotation Goals: Practice-based
Learning and Systems-based Practice
► Integrate
knowledge from medical journals
and research into patient care
► Assimilate feedback from supervisors
► Identify knowledge and skills gaps and
develop individualized learning plan to
address these gaps
► Identify resources and barriers to accessing
health and HIV care in Gaborone, Botswana
The Facts of
Life
Breaking down the day
at Marina
A Few Basic Facts
►
►
525 bed hospital, usually has > 600 pts in house
Separate Male & Female Medical Wards
 Supply Closets, RN Room, MD Room, Procedure Rooms
 Isolation rooms for patients with MDR TB
►
►
►
Patients can also be on the Eye & Private Wards
There is technically an ICU (but it is a Surgical ICU only)
Staffed by:





Specialists = Attendings
Medical Officers = Residents
Interns = Interns
Medical Students from everywhere
Nurses (mostly from Botswana)
Resources at Princess Marina
Resources at Princess Marina
► Nurses
► Radiology
► Labs
► Microscopy
► Computers
Nurses at Princess Marina
► Head
Nurse
 In charge of floor mgmt,
ordering meds & supplies,
administration, etc.
► Floor
Nurses
 1 per 8 or more pts
► Clerk
 Check vitals, help gathering materials
Approaching the Nurses
► Not
so different than anywhere else (but
you will receive a lot of coaching on it)
► Be friendly, considerate
► Do not lose your temper
► Realize they have been doing a very hard
job for a very long time. Keep perspective!
What to Expect…
► Nurses




will:
Administer drugs
Update family members
Co-facilitate family meetings
Write separate admission
notes (very helpful)
What to Expect…
► Nurses
will not:
Place IV’s
Perform phlebotomy
Give IV meds if no IV in place
Deliver/retrieve labs, X-rays,
etc
 Bathe patients
 Always administer PRN
medications




What to Expect…
► Nurses
will not:
Place IV’s
Perform phlebotomy
Give IV meds if no IV in place
Deliver/retrieve labs, X-rays,
etc
 Bathe patients
 Always administer PRN
medications




Radiology at Princess Marina
Radiology at Princess Marina
► Studies




Available:
X-Rays (can be done the same day)
CT Scans (1-2 days)
Ultrasounds (2-3 days)
Echos (variable)
Radiology at Princess Marina
► Studies




Available:
X-Rays – Read by Medicine housestaff
CT Scans – Read by Medicine housestaff
Ultrasounds – Read by tech (you get the report)
Echos – Read by Specialist (you get the report)
Labs at Princess Marina
► No
phlebotomy
► No daily labs
► No notification of critical values
► Not all lab tests are available (even basic
ones)
► Labs are picked up 1-2 times per day
► “Stat”(ish) labs should be hand-delivered
► Results are posted in the computer
► Labs are lost with some frequency
Microscope Room
► In
the Male Medical Ward
► Has reagents for Gram Staining
 Methylene Blue, Iodine, Decolorizer, Safranin
► Ask
about this…
Computers at Princess Marina
► Used
for:
 Lab order entry
 Lab result retrieval
 Internet access (slow)
► Often
► Slow
unavailable (only 2 per ward)
A Day in the Life…
Basic Daily Schedule
► 7:00
– 7:30
Get up, walk to work
► 7:30 – 8:30
Morning Report
► 8:30 – 12:00 AM Rounds
► 12:00ish
Lunch
► 1:00 – 2:30
Family Time
► 2:30 – 5:00
Afternoon work
► 5:00ish
Walking home
07:00 Get Up & Walk to Work
07:30 Morning Report
07:30 Morning Report
► Hear
about Overnight Admissions
 Call for your team starts at 7AM, lasts 24 hours
 A nightfloat admits overnight
 There is a lifelong bounce-back policy
► Hear
about patient deaths
► Review radiology
► Teaching & Presentations
08:30 Rounds
08:30 Rounds
► The
team rounds on all patients, usually
with the Specialist (Attending)
► All labs are drawn, IV’s placed
► Check the computer for new lab results
► Progress Notes written at bedside (they are
brief and to the point)
► Admissions may arrive during this time
12:00 Lunch
13:00 Family Visiting Hour
13:00 Family Visiting Hour
► Not
like Visiting Hours in the US.
There are A LOT of family members!
► Family members bring food, bathe patients,
and sometimes additional medications
► Not a good time to draw labs
► A very good time for family meetings …
Family Meetings
► Ask
the nurse to set them up
► The nurse must be present
► Find a quiet space
► Plan ahead, think about:




Breaking bad news through a translator
Cultural differences in expression of grief
There is still stigma around HIV
Not all your patients are Motswana, be aware!
14:30 Work Time
14:30 Work Time
► Family
Meetings
► Lab Draws, IV placement
► Procedures
► Paperwork
► Admissions
► Dealing with the unexpected…
14:30 Work Time
17:00ish Head Home
Questions
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