International Medicine Elective: Botswana

1. Global Health Programs International Medicine Elective: Botswana Welcome

2. “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.) Greetings Are Very Important

3. Partnership Overview

4. 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

5. 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.

6. 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.

7. Botswana-UPenn Partnership in 2009 • 4 Major Initiatives in Botswana • Clinical care: HIV, TB, Women’s Health. ~ 55 fulltime BUP employees in Botswana, including 15 doctors and researchers • 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

8. 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 side-by-side with UB medical students.

10. 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

11. 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 of Washington • I-TECH • Vanderbilt

12. Sharing the expertise of a world-class university with our partners in Botswana to build capacity and excellence in clinical care, education, and research.

13. Botswana

15. 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.

16. 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.

17. 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 People

18. 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). Religion

19. 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)

20. 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 Political History

21. 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.

22. 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.)

23. 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

24. 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 mid-1990s.

25. 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

26. But… • Large gap between rich and poor • High unemployment • Women head half of households • Mining hit hard by worldwide economic downturn • HIV / AIDS

27. HIV & TB

28. HIV Epidemic UNAIDS Global Report 2008

29. HIV Epidemic: Sub-Saharan Africa

30. 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

31. Batswana Life Expectancy • 49 yo (1966) • 70 yo (mid 1990s) • 48 yo (2005)

32. 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 Why is HIV / AIDS so Prevalent?

34. 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.

35. 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

36. 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%

37. 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

38. Your Clinical Rotation

39. 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

40. 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: What you See

43. 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.

45. 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.

46. Botswana: Who Thrives • Personal characteristics for a successful experience at PMH: • 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

47. 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.

48. 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

49. 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

50. 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