Penn doctors, nurses, and scholars are collaborating with their counterparts in Botswana to try to change the course of HIV/AIDS (and health care itself) in one of the countries hit hardest by the disease.

By Susan Frith | Photography by Rick Cushman

(Above) Dr. Stephen Gluckman, clinical director of the Penn-Botswana program, thought that the country would be a good place for Penn medical students and residents like Marah Gotcsik M’07 to get some overseas experience. The inpatient wards at Princess Marina Hospital in Gaborone, Botswana, are a far cry from HUP.

Around daybreak the patients start showing up at Botswana’s largest HIV clinic. Most are women, who “seem to bear the brunt of the disease,” according to Dr. Mpho Sebonego, a Penn-supported doctor working at Princess Marina Hospital (PMH) in Gaborone. It’s first-come-first-served, so they sign in and sit on benches, talking with one another to pass the hours until they’re seen. The waiting room is air-conditioned, but that’s hard to tell with the outside doors always kept open.

“That’s my people for you,” Sebonego observes in an email. “The heat would be unbearable outside, but they would have the air-con blasting with doors open.”

Despite his occasional sarcasm, Sebonego has wanted to be a doctor for his people since he was a “wee lad” growing up in a rural village 50 miles southwest of the capital city. He studied medicine in the Caribbean, England, and the United States, but he’s back in his home country at a time when more doctors are sorely needed.

With an estimated one-third of its citizens ages 15-49 infected with HIV, Botswana is both a trouble zone and a bright spot in Africa. Its diamond mines have fueled its economic growth, and it has a government determined to do something about the epidemic. For the past six years, Penn has been a leader in this effort and is expanding its presence in ways that may shape health-care throughout the country.

“HIV crosses every discipline you can think of,” from legal rights to business productivity, says Dr. Harvey Friedman, director of the Penn-Bostwana program. “I thought it was very important to open it up to as much of the University as possible. It just expands the impact of what Penn can do there.”

Last summer Provost Ron Daniels traveled with a Penn team to Bostwana and found the program to be “a wonderful exemplar of so many things we’re trying to achieve at Penn,” from international engagement to bridging theory and practice. “We saw there were lots of opportunities for us to harness the rich array of intellectual resources at Penn in collaboration with the University of Botswana around the multidimensional challenges of AIDS,” he says.

Dr. Musa Dube, an associate professor of theology and religious studies at UB who is interested in how gender relates to HIV/AIDS, is looking forward to a widespread collaboration with Penn and a related NIH grant that would free up some of her colleagues from their heavy teaching loads and give “a lot of time and space to do research,” she says, adding: “As we exchange ideas, hopefully we will be able to inject [Penn] with the diversity of an African perspective,” she says. “We’re [also] hoping to learn from their scholars and institutions,” from Penn’s Center for AIDS Research and medical school to its gender-studies programs.

Dr. Stephen Gluckman, clinical director of the Penn-Botswana program, has two kinds of patients back in Philadelphia: those who get a bit frustrated that he’s gone five months out of the year (and who often find another M.D.) and those who think his overseas work on infectious diseases is “pretty cool,” he says. Some of the latter make donations to the program. One patient has even bought a house in Gaborone to serve as living quarters for some of its participants.

Gluckman’s involvement, and the program itself, began in 2001 with a request for help from the African Comprehensive HIV/AIDS Partnership. The Merck Foundation, the Bill and Melinda Gates Foundation, and the government of Botswana had formed a partnership to provide antiretroviral drugs to the country’s infected citizens. Could Penn send some doctors to train medical professionals in using the medication?

Friedman, who is chief of the infectious-diseases division at the Hospital of the University of Pennsylvania, called upon four doctors, including Gluckman, a professor of medicine and the division’s director of clinical services.

“There wasn’t any concept at the time that Penn’s involvement would be ongoing,” says Gluckman. When he first went to Botswana, he recalls, “It was meeting after meeting, and sort of boring. So I asked, ‘Where is the local hospital?’ They pointed me to Princess Marina, and I went over there and sat in a couple of conferences and asked if I could do rounds with them. That was a three-month stint, and by the end of it, I had my own [medical] service.”

Gluckman thought that Botswana would be a good place for Penn medical students and residents to get some overseas experience. He and Friedman got seed money from the medical school and HUP to launch a small program. “Everything expanded rather dramatically from there.”

The inpatient wards of Princess Marina were, and are, a far cry from HUP. “When you do rounds in the hospital most days, they are over-capacity, with patients lying on the floor on mattresses,” says Friedman, who does most of the administrative work and program-building back in Philadelphia while Gluckman works on the wards in Botswana. “There’s TB in many patients, and there is no isolation ward. And they might have sinks on each ward, but there’s no soap. And if there’s soap, there are no towels.”

“When we got there, there was no teaching in the hospital at all,” Gluckman adds. “There was no signing out when people left, no handing off of patients, and essentially no coverage [by doctors] on the weekends.”

Change has been slow: It happens during the morning meeting, or grand rounds, when all the doctors gather to talk about newly admitted patients and interesting cases. It happens in the oupatient HIV clinic and in the wards, where medical teams of Penn doctors and their local counterparts work together to treat conditions ranging from hypertension to tuberculosis. It happens in four weekly educational conferences set up by Penn.

“Most doctors there are just hired by the government and they have a contract to work,” Gluckman says. “There is nothing in their contracts that says they have to care, or to read about medicine, and it has taken a fair amount [of effort] to get them to buy into why all that stuff is good. [But] they have bought into it, and that’s been really gratifying—in many ways more so than the individual patient” encounters.

(Above) Medical students accompany Gluckman on rounds, when newly admitted patients and unusual cases are discussed. Gluckman spends five months out of the year in Botswana.

“It’s a remarkable impact that, in a very quiet way, Penn has had,” says Provost Daniels. “What Penn has done is place its medical personnel into the hospital, and of course that had an immediate effect on the quality of patient care, but more than that, it’s had a broad effect on raising the standards of professional excellence in the hospital.”

The differences are amazing, adds Dr. Scott Halpern Gr’02 GM’03 M’03, a fellow in pulmonary and critical care who went to PMH as a fourth-year medical student in 2001, and then as a senior resident in 2005. “We went from a system in which there was no such thing as a computer and very few drugs available to treat common things, let alone almost no drugs to treat HIV, to lab tests ordered on the computer and patients tracked on the computer and a state-run, reasonably widely available antiretroviral drug program. The one constant was the overwhelming illness seen in the inpatients. It makes what we do in America seem tame by comparison.”

Penn medical students and residents planning to work in Botswana can download a handbook that outlines protocols for grand rounds, polite greetings in the local Setswana language, and even good places to eat. But one thing it can’t prepare them for are the deaths they will witness. “One of the things they’re going to see, guaranteed, every day is people dying of things there that they won’t die of here,” Gluckman says.

Dr. Jason Kessler, who came to Botswana as a clinical instructor shortly after finishing his residency at Penn and most recently headed up Penn’s HIV-TB co-infection program there, says he was shocked at first by the level of illness he encountered.

“One of my earliest experiences here in Botswana that stands out in my mind involved a young man in his early twenties. He was admitted to the hospital with signs of meningoencephalitis (infection of the brain and its surrounding tissues) and was begun on antibiotics for a presumed bacterial infection.

“This unfortunate young man was delirious, feverish, and his family had brought him to the hospital after his condition continued to deteriorate at home,” Kessler recalls. He was also found to be HIV-positive, though it was not clear whether the two conditions were linked.

After seeming to stabilize over the next day or so, the patient fell unconscious. “We tried desperately to initiate the measures I was used to as a trainee in the U.S.—paging doctors, starting IVs, resuscitation—but as we continued our efforts, which seemed to be getting nowhere, the patient began groaning,” Kessler says. “Loud, awful groans that reverberated through the ward, causing all the [visiting] families in the area to turn and watch us as we struggled. It wasn’t more than a minute or so later that the patient arrested and died in front of us all.

“The suddenness and the fierceness of death stunned and shocked me,” he says. “I don’t think I had really witnessed anyone, especially someone so young, die in my presence. Of course, I had been present at ‘codes’ during residency but that experience was more similar to a drill—a bunch of people in a room carrying out different tasks in a generally organized fashion. The patient seemed almost irrelevant and completely dehumanized. This was something so completely different and disturbing. It opened my eyes to the nature of illness here—people my age or even younger dying every day, and my limits as a doctor to help many of them.”

Halpern remembers a 17-year-old boy who couldn’t walk around, or even breathe easily, because rheumatic heart disease had destroyed his aortic valve, leading to “horrendous heart failure.” In the United States the valve could have been fixed surgically, but there were no specialists in Botswana to do this. “We worked for the better part of 2 1/2 weeks to try to convince the government to issue him a passport so we could transport him to South Africa, where there are cardiac surgeons,” Halpern says. “Ultimately we could not get him that passport in time. He literally died due to the lack of a passport.” Now it has become much more routine to transfer patients who need specialized care, though a larger goal is to bring those specialties to Botswana itself.

At times the Princess Marina Hospital resembles a mini-United Nations, with Cuban, Egyptian, Chinese, and Ukrainian accents mixing in the wards with the local English and Setswana. Until recently, Botswana has had no medical school, and most of its doctors hail from other places. (“One of our earlier years there we had a holiday party and asked everybody to bring a dish from their home country,” Gluckman says. “That’s where I got an idea of how many home countries there were.”)

With the low salaries it pays, the government has had little luck luring home the citizens it sends out of the country on full medical scholarships. “The government policy has been that as soon as they get done with medical school, they return home without any formal postgraduate training, do a year of internship—apprenticeship, one might say—at one of the two referral hospitals in the country,” Sebonego says. “After that internship they are posted to hospitals around the country as medical officers … They just learned on the job. Nothing was standardized. They were just thrown into the deep end, and it became sink or swim.”

That’s one reason Penn’s presence has been so helpful, he says. “Through Penn we are able to temporarily get specialties and sub-specialties such as neurology or dermatology that we do not have in government hospitals … some of which do not exist in the entire country.” He’s glad to see that situation slowly changing with Penn’s development of an accredited internship program there.

“I think it is going to have a lot of positive impact on the quality of young doctors coming out of school to work in Botswana,” Sebonego adds. “For the first time their teaching will have a formal component.”

“AIDS in Africa is not a medical problem,” Gluckman says. “It’s a social and economic problem.” Botswana, a former British protectorate that became independent 40 years ago, has a progressive government with good economic resources. “South Africa has resources, but it’s mostly had a government in the way [of fighting AIDS]. Zambia has a reasonable government, but [few resources]; Namibia has neither. Each country has its own issues, and it’s incredibly naïve to blame the problem on a lack of being able to afford the medications.” In fact, he says, without a medical infrastructure to effectively manage the disease, from the pharmacists to the lab technicians and the nurses, the medicines are worse than useless. “If you screw up, the virus becomes resistant.”

Fortunately, that infrastructure is growing in Botswana. In a few short years, for example, it went from having one clinic dispensing antiretroviral drugs (at PMH, now one of the largest HIV clinics in the world) to 32 such places around the country.

Gluckman also commends the government’s decision to automatically test for HIV anyone who comes to the hospital unless they opt out—a recommendation only recently made by the U.S. Centers for Disease Control and Prevention. “If you use informed consent”—testing only those who have undergone prior counseling—“you’re making the disease special and more stigmatized,” he says. “You don’t get informed consent before you test someone’s liver.”

As a result of the extensive testing and widespread availability of antiretroviral drugs, about 70 percent of the people who need treatment are receiving it, compared to an average of only 10 percent in all of sub-Saharan Africa.

According to one measure, the prevalence of HIV among Botswana’s adult population dropped from 38 percent just a few years ago to 34 percent, says Friedman. And among 15-19 year olds, it has fallen 5 percent, to about 14 percent of that population.

Then there are other signs of hope that are less easy to quantify: “A few years ago the coffin makers couldn’t keep up with the demand, and now they can,” Friedman says.

HIV patients are also coming into the clinics less visibly sick than they used to, according to Sebonego. Still, he worries. Over the long term, he wonders if the funds for the costly antiretroviral drugs will dry up. He thinks more emphasis should be placed on prevention. “I just hope my countrymen could adopt the ABCs, as have been preached: Abstinence, Be Faithful, and Condomize. That would make a heck of a difference with regard to the incidence and prevalence, I think.”

That message is being sent—on billboards and in school texts, but it’s not necessarily getting out, says Dr. Bagele Chilisa, a University of Botswana professor and HIV/AIDS-prevention researcher. One problem is that most communications are in the country’s official language of English instead of the national language of Setswana or any of the minority languages. But the communication is ineffective for another reason, Chilisa says: “It’s the language of the laboratory … We’ve tended to teach the biomedical facts about HIV/AIDS, but what the children and people know are the experiences of suffering and pain, and all that goes with it.”

Dr. Loretta Sweet Jemmott GNu’82 Gr’87, the van Ameringen Professor in Psychiatric Mental Health Nursing, and her husband, Dr. John Jemmott, a professor at the Annenberg School for Communication, have spent 15 years working on AIDS prevention. They hope to adapt their research in the United States and South Africa to bring “culturally appropriate interventions” to the adolescents of Botswana. “How do you get people to see themselves at risk, and then to negotiate safer sex strategies?” asks Sweet Jemmott, who worked with at-risk African-American adolescents and their mothers on similar questions [“And Still I Rise,” November 1997].

“The biggest challenge in southern Africa is that sex is such a big taboo,” John Jemmott says. “It’s an even bigger taboo than in the United States, where parents are reluctant to talk to their children about sex.” If sex can’t be talked about, things like condom use can’t be negotiated, which puts women at a greater risk in this male-dominated society.

“Men have the final say. And men decide when to have sex, and how to have sex,” says Chilisa. “Especially when you are married.”

The ABC strategy is not always realistic, UB’s Musa Dube adds. “Whether you can practice the ABCs depends on the gender power you have in your relationships. If she’s suspicious that her husband is seeing someone else, that doesn’t mean she has the right to have her husband put on a condom.”

The older women might even take aside a new bride and give her some advice: “They’ll say her husband might not be home some evening,” John Jemmott says. “When he comes home in the morning, she should prepare a bath and breakfast, but she should not ask where he’s been. If he beats her and she gets a black eye, she should say she got up in the evening to go to the toilet and walked into a wall. Neither infidelity nor battering are grounds for leaving her husband.”

Poverty, and high unemployment, also feed the disease. Dube talks of Botswana’s sex-workers, saying, “Even if you’re preaching abstinence, even if they know they should be using condoms—if they’re hungry, they’re hungry.”

(Above) An AIDS patient receives care in the outpatient clinic at Princess Marina Hospital, one of the largest HIV clinics in the world. Once it was the only one in the country, but now 32 such clinics dispense antiretroviral drugs.

With a significant portion of Botswana’s adult population infected with HIV, the virus carries an enormous economic and social cost. “That’s the economically active age group, and the sicker they get, the more debilitated industry becomes,” says Jim Thompson, associate director of Wharton Entrepreneurial Programs and co-creator with Management Professor Ian MacMillan of the school’s Societal Wealth Generation Program (SWGP). “We started to think about how we might intervene with [information technology] or other alternative assets and demonstrate there’s a way to keep the workforce more vital and extend lives at a lower cost.“

The SWGP is working with a private medical practice in Botswana to see if cellular-phone text-message reminders will improve the rate at which HIV patients refill prescriptions, visit physicians, and reduce their viral loads. The technology would help address the country’s current shortage of doctors and nurses, freeing up medical workers to concentrate on the sickest patients, Thompson says.

“If we’re successful, we’re hoping we could expand this to cover malaria and TB and other critical diseases, and [that] somebody else might be able to use this in other parts of the world.”

Expanding on the potential of information technology, Thompson envisions the development of an electronic health record with built-in treatment protocols that could provide enough support for the front-line medical workers, such as certified nurses, to care for patients who are in stable condition or who have just been diagnosed with HIV. When necessary, Thompson says, a physician could look at the patient’s electronic file and say, “‘I think that’s enough information. Here’s what I’d recommend,’ or ‘Here’s a referral. This patient needs to come in.’”

In addition, Penn’s nursing school will be working to improve “care at the bedside” in Botswana. Beginning this summer, small teams of nurses with expertise in leadership, oncology, and trauma nursing will be sent for 12-week stretches to train local nurses and help them improve patient care, according to Dr. Victoria Rich, chief nurse executive for The Penn Medical Center and assistant dean for clinical practice at Penn Nursing.

It’s been almost three decades since Rich herself was involved in clinical nursing practice. But on a visit to PMH last August, she was saddened to see that she could step into a ward there and still know what to do. “That’s how behind the times they are,” she says, noting gaps in infection control, supplies management, and other processes that are taken for granted in U.S. hospitals.

“There’s one blood-pressure cuff for 20 patients, no IV pumps, and no infrastructures to see if they need supplies and equipment. On a 30-bed unit they’ll have 60 patients, and there will be people lying in a sleeping bag or on a blanket on the floor,” she says. “But the people want to learn … and to take care of their own.” And “their validation of human existence is at a level much higher than I think we have in the United States: their sense of not being prejudicial, just making do with such minimal things, but making do in a dignified way.”

For an hour each afternoon at PMH, the visitors crowd in and most medical work comes to a halt as family members stand elbow to elbow, bringing food, prayers, and encouragement to the patients. “It’s just incredible devotion—devotion we don’t always see here” in the U.S., says Scott Halpern.

Dube has begun to see something else in the interactions of people in her country. “I feel like we’ve been through it all [with HIV] and we’ve reached a point of acceptance, of living in hope,” Dube says. “There are two phrases I’ve found that have become phrases people use in day-to-day talk:

“Otla fola: You will be healed.

“Go tla siama: It will be OK. It will finally get right.”

Chilisa, her colleague at UB, maintains a gloomier outlook. Even the antiretrovirals that allow patients to feel better may delude them and their lovers into thinking they’re well enough to have unprotected intercourse. “We will wait and see what happens.”

Dube acknowledges the problems that remain, such as patients who are living longer, but are unemployed. Now the government has to decide whether it can pay for both food and medicine. But she says she’d rather have “a crisis with hope than to have one with no hope at all.”

“I think we are living in an HIV-positive world,” Musa says. “It’s not just a Botswana problem or an African problem. The world has been living with HIV for 25 years and it has brought us to realize that we are interrelated, so the structures that maintain poverty anywhere must also interrogate their contribution to fueling and maintaining the HIV/AIDS epidemic. We have to own up and ask ourselves how can we create a world that is better for all of our citizens. It should begin with all of us.”

For a handful of Penn doctors, it begins with each day’s rounds. “I think we’re making an impact,” Friedman says. “We’re one of many, but we’re doing our part.”

Dr. Jason Kessler remembers another confused and feverish young man who came under his care at PMH. The patient had never been tested for HIV, but he had the telltale signs of chronic infection: thinning hair, oral thrush, and wasting syndrome.

“We saw him the morning after he was admitted and immediately ran into his sister, who was very concerned about him and related to us that, unlike what he appeared like now, the patient was actually a very accomplished young man. He had trained as a lawyer in Europe and was quite successful.”

The doctors would do what they could, Kessler told her, but the prognosis looked poor.

Then a CAT scan found masses in his brain, which explained his cognition and orientation problems. He appeared to have an opportunistic infection called toxoplasmosis, Kessler recalls. With treatment the patient was able to check out of the hospital two weeks later. “I continued to see him in the HIV clinic at the hospital and started him on antiretroviral therapy.

“Within six months he was nearly completely well, back at work and his charismatic old self. I still see him or his sister now and again around town and they never fail to recognize me and greet me with warmth and thanks,” Kessler says. “So I learned to accept the difficult or terrible outcomes, but I realized that every so often, we are going to alter the course of the epidemic in a young person’s life.”

Susan Frith, formerly the associate editor of the Gazette, is a freelance writer who lives in Florida.

The Penn-Botswana program has four components:

Clinical care and education. Penn has signed agreements with the Ministry of Health to take part in medical care and educational programs at Princess Marina Hospital (PMH) and Nyangabgwe Referral Center in Francistown, and—on a rotating basis—nine surrounding district hospitals. A federal grant through the President’s Emergency Plan for AIDS Relief supports six full-time Penn doctors in the country. The University is also developing a clinic for HIV patients with opportunistic infections and metabolic problems.

Global health experience. Over the past two years, more than 100 Penn medical students and residents have worked in the hospital wards of Botswana. This academic year about 35 fourth-year medical students and a dozen or more infectious-disease fellows and residents in internal medicine and specialties such as dermatology and emergency medicine, will do electives there.

Research: Through the Center for AIDS Research, Penn and Batswana researchers are studying, among other issues, meningitis, tuberculosis, and the treatment success and failure of patients on antiretroviral drugs. (People from Botswana are called Batswana, not Botswanans. One person from Botswana is Motswana.)

Collaborations: This fall Penn signed an agreement with the University of Botswana (UB) to create collaborations in medicine, nursing, and other disciplines. UB is forming Botswana’s first medical school, and as part of that effort, Penn will develop a curriculum for a rotating internship at the country’s teaching hospitals as well as post-graduate residency programs in internal medicine and other specialties. In addition, Wharton’s Societal Wealth Generation Program has launched a health-care study in the country to reduce the effects of HIV on its workforce; the nursing school is sending professors over to teach the “best practices” of their profession; and researchers from the nursing and Annenberg schools are looking for ways to reduce the risk of HIV transmission among Batswana adolescents. This spring, Penn undergraduates are taking part in the University’s first semester-abroad experience in Botswana.

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