The more I learn about health inequality, the more I realize that the underpinning of inequality is tied to imperfect social structures, infrastructure deficits, and issues of governance. I could run around treating patients for a hundred years without ever impacting the true root of inequality, and the origin of poor healthcare has to be addressed farther back than at the bedside. It has to be addressed at the level of medical education and health system development. Once you have good doctors and a good standard of care centrally, it becomes possible for that standard to spread through information highways more peripherally. To approach the problem the other way around is to swim upstream. So despite my love for the jungle, cold showers, and the romance of resource-limited medicine, I have to see what the central standard can become. That’s why this elective in Botswana through their partnership with the University of Pennsylvania is so important.

Botswana, a landlocked nation in Southern Africa (north of South Africa, and sandwiched between Namibia and Zimbabwe), is made up of mostly desert and flat plains. With a population of just over 2.5 million, it is incredibly sparsely populated. Historically, Bots was a nation of organized chiefdoms existing on agriculture and cattle until being annexed by the UK during the scramble for Africa in the 1800s. British rule, from what I gathered in my readings, was relatively un-contested and free of bloodshed, and in the 1960s the chiefdoms collectively negotiated sovereignty for Botswana. Since independence, Botswana has experienced one of the fastest growing GDPs in the world, propelling itself from one of the poorest countries to an upper-middle income economy with one of the highest standards of living in Africa. This has been influenced by both an abundance of natural resources (diamonds and other raw minerals), a well-developed tourism sector with upscale safaris in the Kalahari desert and Okavango Delta, as well as sound economic policy and stable politics (they have democratically elected the same party every election since 1966). Botswana is as stable, safe, and prosperous as one could expect from a country so young.

With Botswana’s economic status improving, its health infrastructure has also improved, although it still has gaps. Botswana was hit particularly hard by the HIV/AIDS epidemic, seeing a life expectancy drop from the mid-sixties to the mid-fifties before and after the arrival of HIV until returning to its previous baseline finally in the late 2010s. Today, around 20-25% of all Botswanians live with HIV, which has made it an international hotbed for HIV research and program development, now with a state funded program providing treatment without direct cost to patients. Additionally, the University of Botswana health system has seen an impressive amount of development since 2000. Through the assistance of the Upenn-Botswana partnership, as well as support from both Harvard and Baylor, the University of Botswana started the first medical school in the country, followed some years later by the first internal medicine specialist residency program, and just this year in 2024 they are welcoming their first cohort of radiology residents. This is what health structure development looks like. 

I was getting the chance to see this firsthand through a six week attachment as a visiting resident via the Upenn-Botswana partnership at Princess Marina Hospital in Gaborone, the nation’s capital. It was a two year process that started when I first arrived in Philadelphia to get the elective approved.

After spending a three day layover in Cape Town as a tourist, I touched down in Gaborone airport on a Sunday evening to the captain’s announcement that it was 51 degrees on the tarmac.

Good thing I packed sunscreen.

I was impressed at the state of the airport; it was clean, modern, although relatively empty. At the gate, I was met by the Botswana-Upenn (BUP, for short) driver, Uncle David, who showed me the important sites like the University, shopping centres, the hospital, and the national stadium. The sizzling Kalahari sun flattened a landscape of wide asphalt roads and sparse high-rises, more suburban city than metropolis. Thin foot traffic, which initially surprised me, was a byproduct of the diffuse urbanisation and the city’s small population (around 235 000).

After waving goodbye to Uncle, I checked out my apartment. It was a considerable step up from any of my previous global health projects, complete with granite countertop and air conditioning. Despite feeling lavishly spoiled, I saw a roach near the kitchen a few days in which made me feel more at ease. I identify with the roaches; they’re just trying to make it like you and me.

Next I walked to the nearby mall. That’s right, mall. Unbeknownst to me, the Gaboronians had an obsession with building malls. There were malls everywhere. The concept of street shops or a walkable city centre was replaced by shopping centres akin to the suburbs of North America. I realised very quickly it would be incredibly difficult to get around on foot, and the public transport infrastructure was outside my scope after having just arrived. There were combis, or little vans that served as public transport, but they were unlabeled without any written resource to know which routes went where. Walking to the mall, there was a combi stop outside, where combis would pull up and honk incessantly while shouting their routes before carrying on. At some point I’ll figure out how this works, I thought, but for the time being I would have to rely on walking and taxis. Walking around felt comfortable; despite being the only white man in sight, nobody seemed to take much notice or pester me for money like I’d experienced in Ethiopia or Uganda. A welcome change.

Monday was a day of clerical tidying. Uncle David took me to the BUP office at the University to meet the administrative staff. There I met Josephine, the main administrator who I had exchanged emails with leading up to my arrival. She was younger than expected, articulate, patient, and wore lovely dresses. I also met her assistant, Mac, who was young, probably in his early to mid-twenties, with clear rimmed glasses. They gave me an orientation about what to expect, things to do in the city, and the process to get my medical licence. Then they led me in to meet the BUP director, a tall Italian, and we shook hands and said hello. Then I got back in the car with David and he took me to the police station to get my paperwork sorted for the medical licence. That took me into the afternoon, where groceries and some more time walking around the local mall kept me entertained.

On Tuesday I arrived at the hospital. It was a complex of single story buildings arranged in wings. Walking through the complex, a main path separated male and female sides of the medical, general surgical, orthopedic, and gynecology-obstetrics wards. All the wards were detached from one another separated by the path, with doors and windows always wide open to reduce the spread of TB.

The wards reminded me of Irish hospitals. The patient beds were arranged into open chambers with six beds, three on either side. Around five chambers in total per wing were arranged in a row, with the nurses station positioned across from the middle chamber reserved for sicker patients. Adjacent to nurses stations you would find a filing cabinet with charts, labelled A through D. The station had an elevated table space at standing height for clinical staff to document from a standing position, and there was a mess of papers everywhere. Privacy did not exist in these wards, and although there were curtains able to be drawn for procedures or sensitive exams, full body exposure with catheters, breasts, and all else were on full display. Each of the main cubicles were the same size, although they also had two isolation rooms on one end of the ward that could handle up to eight patients. I kept to myself as I surveyed the area.

I was met by the chief resident in internal medicine, Dr. K. He was around my age, stocky, with a thin goatee and a button up-shirt. I shook his hand and he walked me through the ward explaining how things worked.

‘We have four medicine teams, arranged by colour and letter. Blue A and B, and Pink A and B,’ he said. ‘You will be assigned to Blue A, and I will introduce you to your resident. The attendings round three days a week, Monday, Wednesday, and Friday. The team rounds with the resident on Tuesday and Thursday and there is no rounding on weekends, although you will hand over any tasks to do for the on-call staff covering the weekend if needed. The teams rotate who is admitting patients in a cycle once a week, and during that time the call team takes all the admissions over the 24 hour period, and those patients remain on that team until discharge. Outside the path here if you walk to the left you will find the intensive care unit on the way to the emergency department and radiology. We also have clinics in the afternoons throughout the week, and you are free to participate in those if you wish. You may find the HIV high risk infection clinics interesting; we do those on Wednesdays. Have you got any interest in the specialty clinics?’

‘Certainly, I said. ‘I would be interested in the high-risk HIV clinic. Also you mentioned the ICU, is that through the department of medicine or anaesthesia?’

‘Our ICU here is through anaesthesia,’ he said, nodding.

‘Nice, okay. I have a fair bit of clinical experience in our medical ICU, would there be any chance of me getting to spend some time with your group here?’

‘ICU?’ he said. ‘No problem, that can be arranged. How long are you here for?’

‘Five weeks.’

‘Okay okay…’ he said, thinking. ‘If you want you can do three weeks here with the medicine team and then two weeks in the ICU. We can give you a chance to get settled into the medical service before you visit some of the clinics. How does that sound?’

‘Sounds fantastic to me,’ I said. I laughed internally thinking back to nightmares trying to get approval to work in other departments all throughout residency because of endless red tape in the US. Why can’t life be this simple everywhere?

‘Good, good,’ Dr. K said. ‘You are still waiting for your medical licence, yes?’

‘I have to return to the Ministry today and finalise some paperwork, but as far as I know the licence will be issued by tomorrow,’ I answered.

‘Alright.’ Dr K continued. ‘Those are the essentials. I will take you now to meet your team and you can participate in ward rounds for today before you are fully licensed tomorrow.’

We walked through the male ward onto the female side and I met the members of the team one by one. Our team had an attending, one internal medicine resident, two medical officers, two interns, and 5 medical students—In Botswana, like in other African countries, physicians are trained incredibly broadly through medical school before completing a mandatory intern year that is split into part medical and part surgical assignments. Physicians can then opt to remain as medical officers, working contract to contract wherever they are hired, or pursue higher specialist training. Many of the medical staff in rural settings are medical officers. In larger academic hospitals, I learned that medical officers occupy a middle rank between interns and residents. My experience in Uganda was not the most ringing endorsement for medical officers, although I am sure there are as many great ones as there are not-so-great—with such a large team, we formed a small army occupying far too much space at the foot of our first patients’ bed. I tried to make myself skinny, wedging in next to the bed as the first patient was discussed. She was a lady in her fifties being treated for a brain abscess, and the case was presented by the intern.

The patient had been referred in from a community hospital because of worsening left-sided weakness and visual changes. She also has a change in her left eye, with a pupil that was pointed down and out and an eyelid that drooped. She also complained of fevers and was found to have rotting teeth draining pus, so she was started on antibiotics and sent to Princess Marina. She had been with the team now for several days, and they were able to get her a CT scan of the brain that showed a fluid collection in her right temporal and frontal lobe. On this morning, I could see from a distance that her left leg was completely limp and turned outward, and her left arm sagged. Her leg was also massively swollen from the result of a blood clot she got as a complication of her immobility. From what I was told, she was improving since starting the antibiotics, and the team was able to get a MRI brain for her through the private sector with results that should become available shortly. The plan was to involve the neurosurgical specialists once the imaging results came back to see if there was any role for drainage.

The case presentation took a while, coloured by a lot of question and answer from the attending, complete with cranial nerve and neurological exams. Every question he posed was met by a deafening silence from the medical students, quivering lambs that dropped their gaze to the floor, mute with shame. The attending, a fifty-something African who did his specialty training in South Africa, bordered on self-indulgence with their lack of confidence, letting the silence stew endlessly before getting to his teaching point. Again, this was exactly like how I remember rounding as a medical student in Europe.

We’re in for a long one, I thought to myself.

And a long one it was. Starting around 9, we rounded until just before 2PM, and my feet were sore by the end. I kept my role to that of a white shadow, trying not to over-step with suggestions and just get a feel for the team and how medicine was done here. At times I was asked to offer an opinion, and I did, with my own follow up question or two to clarify my understanding. One thing I didn’t want to do was be the arrogant outsider here teaching the third world how to practise medicine. In reality, I had everything to learn and very little to offer. I was in a rush to leave after rounds to get back to the Ministry for my in-person validation.

Uncle David drove me to the Ministry, where I was seated in the hallway for ages until they finally called me in. Having collected all my documents the day before, all they did was shake my hand and give me a pep talk before shooing me out to try and drop my materials at the licence issuing office before they closed at 3:30. Even though the issuing office was 10 metres up the hall, when I got there, of course they were closed. This meant that David would have to return the following day on my behalf to pay the issuing fee and collect the receipt. In the end, my licence would get approved but never actually issued, because of some technical error with the system that was outside of my control. 

Maybe one of my roach’s cousins got caught up in the wrong fuse box.