Dear Friends: It has been 10 days since I arrived in Africa. I left Philadelphia at 5:40 am for Atlanta, and waited 3 hours there for the next flight. The flight from Atlanta to Johannesburg, South Africa is the longest I have ever been on, 18 hours including an hour refueling in the Canary Islands. Then after another 3 hours in Johannesburg, it was an hour on a prop plane to Sir Seretse Khama International Airport in Gabarone, an unimposing one-story brick building with one gate.
I was picked up from the airport by Gill, a white Motswana (singular for Batswana, the name for the people of Botswana) who has lived most of her life here, with brief stays in the UK for training in her youth. She and one of the other residents brought me to the ICC flats, a gated community where Penn has rented two apartments for the rotating physicians and medical students who come to work at Princess Marina Hospital. The flats are largely expatriates, and when I asked about identification, I was told that the guards would know I lived there because I was white. "There aren't many of us here," explained the other doctor.
Marina is the largest hospital in the country, serving as a referral hospital for specialized services, and for opinions from specialists not available at the regional and local facilities. Nyangabgwe Hospital in Francistown (about 8 hours by car to the north) serves as the referral hospital for the northern part of the country. Many special services, including CT scans, and consultants such as oncologists, are only available at Marina or Nyangabgwe, and some such as neurosurgery, are only available at one of them. If patients need cardiac surgery (such as valve replacement for rheumatic heart disease), angiography, or other high-technology procedures, and they are citizens of Botswana, they are sent to private hospitals in neighboring South Africa and the government pays the bills. In practice, some referrals to Marina are for end-stage patients for 'further management,' and in my experience these patients are already dying on arrival, or for services such as blood transfusion or oxygen therapy, which are supposed to be available at all hospitals, but are often not because of short supplies. (In fact, last week Marina ran out of B-type blood for 2 days, and the previous week ran out of oxygen.)
All nurses are Batswana, but all doctors are foreigners or foreign-trained. Botswana has just opened its first medical school and now has students in the third year. For 40 years since independence in 1966, they have sent their bright young people to the US, the UK, the Netherlands, South Africa and elsewhere for medical education, but many do not return because of better conditions and higher pay where they train. Of the 500 would-be doctors sent abroad in the past 30 years or so, only about 100 have returned. And since only citizens can hold jobs in the Ministry of Health, many of the Motswana doctors are there, with others in private practice. Since patients are most likely to speak English if they are under 30, we often need translation from Setswana, either from a nurse or a Motswana doctor (in the male ward where they often have neither, it is sometimes the patient in the next bed). I have been taking lessons, and have only a minimal knowledge - I can ask if they are better, if it hurts here (pointing), and would they breathe deeply. More complex questions require translation, no so much because I can't ask the questions, but because I can't understand the answers. I quickly realized that when talking to a family who speaks only Setswana about a death, my job is simply to look sorry and ask the nurse if they have any questions. Delivering the news becomes her task, as my Setswana is simply not up to such a delicate task.
Princess Marina reminds me of many places I have seen or read about. First, it is a massive complex in the center of the capital, perhaps 20 buildings, perhaps more. The heart of the hospital complex is built on the pavilion style made so popular in the late nineteenth and early twentieth centuries by the work of Florence Nightengale. The separate single story ward buildings with open walkways between, which allow for maximum ventilation without any mechanical systems, which many of my colleagues assume to be eithepeculiaritycuiliarity or a colonial hold-over was actually the highest technology in tuberculosis prevention a century ago, and surely still serves this function at Marina, where conservatively a third to half of admissions to medicine have 'rule out TB' as at least one of their problems. We are very crowded in the medicine wards at Marina, with a female ward designed for 30 patients in five bays with 6 beds each bay frequently housing 10 patients on beds, 2 on mattresses on the floor, and one around the corner in the hallway. On Tuesday when my team was admitting, they just kept pushing the stretchers in despite the fact that there was no place for them to go. I think we must have peaked at about 75, and one could barely walk out of the ward around the traffic jam of sick patients.
Marina also reminds me of the nineteenth century hospitals of Paris and other major cities, including those in the US. But as a grand complex with open wards, and very sick and often dying patients, it is more like the charitable facilities that were run in the nineteenth century, where patients went only if they had nowhere else to go, and in which they expected care but cure was usually beyond them. Eighty-five percent of the patients admitted to Marina are HIV positive, with many admitted to medicine for end stage HIV/AIDS, cryptococcal meningitis, tuberculosis of the lungs, joints, and many other parts of the body. The population as a whole is more like 40 percent HIV positive, with a skew toward the young and working-age population (about 55-60% between 18 and 49). These are the highest documented rates in the world, but interested observers believe that the rate is actually similar in neighboring South Africa, Zimbabwae, and other nations, and that Zimbabwae is too chaotic to survey, and South Africa too deep in denial. "This virus is tearing us apart," said one of the administrators at Marina to me. The President and the country's leadership realize that they have to fight HIV.
At the same time, Marina sometimes has late twentieth century technology, including ultrasound, echocardiography, a CT scanner, lab testing, and medicines from penicillin to streptokinase (a clot-buster used to stop heart attacks in progress. Then again, there is no ciprofloxacin in the country, and my first week we ran out of most of the different kinds of IV fluids. The tuberculosis patients cough on each other, and on the staff (the nurses wear surgical masks, but apparently no one has told them they are useless for TB - the thicker kind that would offer some protection would be stifling in the un-air conditioned wards and 90+ degree heat).
There are some peculiarities to the use of invasive medical technologies in these conditions. I have long wondered whether hospitals that re-use needles are doing more harm or more good compared to nothing, traditional medicine, or simply refusing to use technologies that cannot be safely administered (then again, I wonder myself about use in any setting of dangerous drugs, especially many chemotherapies, transfusing blood products which could always be tainted, and many of the surgeries or CT scans we do routinely at home with risks of death, organ failure, infection, etc.).
But these academic doubts come to little when I look in the sunken eyes of a woman dying of overwhelming infection, and I will place an IV, administer drugs and oxygen, and tell her family that we are doing what we can. I had such a lady last week, and when I talked with her relatives, her brother said that he wondered if there could be more done with more resources. I looked him in the eye and said that I come from America, and with all of our machines, and medicines, there was nothing we would have done for her there that was not being done. I think that was a comfort - I hope so. I cannot always say that, but when asked, if it is true, I am glad to do so. She died that night.
I saw another patient that day, a lady whose liver had been replaced by cancer, and who was therefore in complete liver failure. When she got worse, I considered giving her a blood transfusion or a transfusion of blood plasma (to replace the clotting factors her body could no longer make). I knew this lady was going to die no matter what we did, and thought perhaps we could delay this by a few days, but no more. At home, we would have tried unless her family declined the care. Here I hesitated. As I told the Motswana physician with whom I work, I would have felt terribly guilty if someone came in later that day after a motor car accident, and died of bleeding because I had used that FFP on a lady who was going to die anyway. He agreed, and we did not give the plasma. She died about 15 minutes later.
While these resources are limited at home as well, they are not so constrained as to offer such direct consequences - usually at home it is about money, and neither patients nor physicians consider that a major factor in treatment decisions at the time of lifesaving treatments. I know we should sometimes be more realistic, and often push both families and the senior physicians to accept the inevitable, but it's a fine balance between accepting what you cannot change and giving up too early on someone who might make it (then again, these issues usually arise at home in patients who have cancer and are known to be terminal, and the argument is about how soon ...
Finally, the level of sickness, the frail, thin, wasted patients remind me of both so many famine relief campaigns and of the early AIDS epidemic in New York. In the mid-1980s, up to 30-50 percent of admissions to medicine beds at hospitals (distinct from surgery, OB/Gyn, and pediatrics beds) were for HIV related conditions. Here it is more. And the people who come in with TB and late-stage HIV can have sunken eyes, flat or sunken bellies, and arms as thin as 2 inches in diameter - if that. Some will recover, many will not. But Dr. Gluckman, one of our senior physicians, says no one should die without at least trying drugs for TB (and HIV if reasonable). After starting an ambitious national HIV treatment plan 2 years ago with assistance from the Gates Foundation and Merck, Princess Marina Hospital has the largest HIV clinic in the world in terms of people under outpatient HIV treatment. They have a multi-million dollar pediatric HIV project in partnership with Baylor University, and a major AIDS research complex associated with Harvard. On the one hand, we are all trying to help, but then again I feel a bit like a voyeur watching a train wreck (an image of vultures also comes to mind) but if I were not here, who would see that Sylvia got her amphotericin every day ...
All this is against a background of a dry but beautiful country, a small provincial capital city, friendly people (though as a white person in a majority black country, sometimes I feel like I am the animal they are looking at on Safari). Last weekend I took some time to recover from the jet lag. This week I ventured to the Main Mall downtown, which with its hand-painted signs, chaotic traffic and layout, street vendors, and yet high-tech services such as cell phones reminded me most of all of small and medium-sized cities in Mexico.
This weekend I, two other residents, and a medical student went to the Kalahari (Kgalgadi in Setswana (the English spelled it wrong again) to see wildlife and scenery. It was hot but not as bad as Gabs had been last week. We saw giraffes, antelope of various kinds (Gemsbok and Springbok in Setswana), vultures and other birds, and a few badgers. While lions have been seen in the Kgalgadi, this is the third year of drought, and there have been many areas burned either spontaneously or as fire breaks, so many of the animals have departed for better grazing elsewhere. Finally, we took a walk with a member of the San, who showed us how to make fire with two sticks, a small stone, and some dry grass, explained how they used the snakes, spiders, and worms to poison their arrow tips, and how they get water from the tubers in the ground.
Now back in Gabs for another week at Marina. I think on balance that the patients I see each day are better off that we are there, though the locals are working hard to teach us about the diseases they see most often, and how to treat many things without all the expensive tests we are used to.
All my love,
p.s. Elise, it was in the 90s Farenheidt all week last week, and in the 80s this week, and no the Penn flats don't have AC. The hospital doesn't have AC, but also doesn't have chairs, more than 1 computer per ward, etc.