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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