Cancer Care in Botswana Continued

So the meeting with the ministry personnel never actually came to fruition, we were unable to connect due to certain time constraints and obligations I was however able to meet directly with her nurse coordinator to share ideas. I got a sense from her that although cancer was had not been a major priority, the ministry of health is not recognizes how important and how significant of an impact it is having on the population.

We discussed the strategies to empower the local clinics and health providers. The hierarchy of health care goes from health post, local clinics, primary hospital, 2^nd hospital, and tertiary hospitals.   So the plan is to map the countries health clinic and posts, identify the numbers of health provides to create an appropriate strategy to educate them. We discussed the most effect mechanisms for educating health workers and her thoughts were that from the HIV and TB initiatives, workshops had been very successful.  I will have to continue to follow from afar.

I want to focus a little bit of my time in the different hospitals.

I spent majority of my 1^st week in Bots at the oncology department of the Gaborone private hospital (GPH). Here the government funded and private patient receive radiation.  So a lot of patients I saw were government funded patients, whom I would have some continuity with at the public hospital. I spent a lot of time assessing the different areas of need.  So I�ll start with that.  GPH is the only radiation facility in the country.  There is only one linear accelerator and a handful (2-3) of radiation oncologists. Because of the volume of patients, there is no room for specialization. They radiation specialist saw patients with cancer of different primary sites, very unlike the U.S, where you really focus on 2-3 disease sites.  There were of course problems such that the scanners were not always functional, which meant patient had to go the radiology department to have their scans. The biggest problem I noted was the lack of human resources, and human capacity. The issues of occasional machine malfunctions were present, but the major issue was the lack of support. For example, in the clinic, the patients generally come in and sit in a cue and they are given a number and they are seen one after another without any form of triage, they are no set appointments, so it is not uncommon for a patient to come into the hospital and sit there for hours waiting for their appointment. There are very few oncologists in Botswana; many of the ones here are expatriates. (A lot of this has to do with the relatively nascent medical school and a handful of residencies that are also relatively new). The government sponsors training of their physicians abroad with the hopes that they will return. However they are presented with better opportunities and incentives and a good portion do not return (but this is an entirely different topic for a different day). Given all the potential problems, there is a lot of hope and room for improvement.   Some physicians are choosing to come back and work in their home country. For a low resources setting, the facility was functioning adequately. Of course there were challenges, but there were a lot of positives. There is a dosimetrist who assists with the radiation plans for patients. There is also one physicist who assisted with QA.  The software that was used for patients� treatment with pretty updated and comparable to the software used at large academic centers in the US.

The sign for oncology ward

The experience at the private hospital was great because I could immediately juxtapose it with my experience at the public hospital. Besides the fact that the facility was a little nicer, the government hospital experience was not very different. The same needs I saw at the private hospital were also very prevalent at the public hospital. The was a lack of triage such that there is no support for the physicians, for example, a patient came in for a follow-up visit while on chemo and mentioned to the physician that she thought her blood pressure might be elevated.  There was no way to adequately record this, a functioning blood pressure cuff was not available in that office space and the patient was tasked to return to a primary health physician. Another noticeable problem at Princess Marina was the space restraints. Because this hospital is a referral center, patients typically travel long distances from their local health posts and primary hospitals. This means that a patient who is coming in with a potential new diagnosis of cancer is sitting in a waiting area that is adjacent to patients in the ward. So as you seat in the oncology cue waiting to be seen by the oncologist, you can see patients who are undergoing treatment for cancer.  The immense psychosocial havoc that could have on a patient is incomprehensible. The question that would have crept up in my mind, �is my fate similar to the fate of the people lying in the beds next to the waiting area? Now I don�t know if this is what the patients thought, but I can only imagine.

The chairs and patients are waiting areas for patients and just beyond the blue cart is the open ward