I was one of four Penn trainees visiting Botswana. Alongside me in the luxury apartment were three medical students. One was a PhD with cardiology aspirations, who would accept no more than an elite combined research residency in California. Another was a Type A high achiever with a chip on her shoulder, keen on a big name Emergency residency in New York City. The third was a fairly normal guy on a gluten free diet who wanted to be an ophthalmologist somewhere in Philadelphia to build a life with his Fiancée. Our programs were different, I was assigned as a resident to Princess Marina for six weeks and they were assigned as students at two sites, first to a health centre in the nearby village of Mochudi for three weeks, followed by a three week stint at Princess Marina. When I met them one week after arriving in Botswana, we developed a connection quickly. After their stay at the village, many of our conversations were about their shock at the scope of practice, lack of resources, and seemingly avoidable decompensations of patients. Similar to the way I was thrust into a physician role while still technically in the oven as a final year medical student in Panama, they found themselves asked to hold responsibility that they didn’t expect. Throughout our time together, after many dinners made and safari tours had, I learned more about their temperaments and career aspirations. By now they had grown dispirited with most things: Princess Marina and its inefficiencies, Gaborone and its lack of culinary diversity, and having to buy bottled water three times a week to drink at home. I remember sitting on the couch with them one evening towards the end and we talked about plans for the future.

‘I could never work here in a million years,’ the future cardiologist said. ‘I am already so frustrated.’

‘Yeah no kidding, I would probably kill myself,’ said the high achiever.

Their words, not mine. Then they both looked at me and we all laughed. I was running straight towards the thing they couldn’t wait to get away from.

I met others in my time here, Botswana nationals (Motswana, as they are called in the local language) both in medicine and not. After getting drinks with a group of them, I was invited to a night of libations and card playing at one of their houses. We sat around a wooden table in the backyard, with drinks and music talking all manner of idiocies. As more new faces arrived I found myself sitting next to a woman in her early twenties with braids and distinctly Southern African features. She worked in digital marketing and grew up like many of the Motswana in a nearby village before being pulled to Gaborone for studies and to build a career.

‘You have worked in Princess Marina?’ she asked when the subject of my work came up.

‘Sure have. Nearly finished my attachment at this point but I’ve been here for almost six weeks.’ I answered.

‘Can you tell me about it?’ she asked.

‘How do you mean?’ I said.

‘Well… There are many people in the city talking about it. Conditions are very bad. It’s a big problem and people know it. It has caused a lot of pressure on the government and been a talking point for the coming elections.’

‘You don’t say,’ I answered. ‘Well, let me tell you…’

So I told her. I told her about my amazement at the quality of physicians and the counterbalance of inefficient frameworks. I told her about some of my cases in my writings, and several others that didn’t make it into these reflections. She peppered me with questions and I answered in kind to the best of my ability.

‘These are the frustrations of Botswana,’ she said. ‘Nothing works here. Everyone is just trying to get out.’

‘I have seen worse,’ I said.

At the same time I understood her position. This is the eternal struggle of smaller nations. Even despite Botswana’s incredible progress, their robust GDP, safe communities, friendly populous, and plethora of natural resources, the brain drain is real. Neighbouring South Africa lures eager talent with far more robust infrastructure for career development, more sophisticated hospitals and expertise. Those who come back to Princess Marina do it out of sheer national pride. If all of Botswana’s best stayed here for just one generation, the benefits would be incredible. Furthermore, of the people I met that night, several of them weren’t Motswana, they were from neighbouring Zimbabwe and Zambia, coming to the University of Botswana for their training. So even within the region, there are brain drains within brain drains. It will make your head spin.

My case study of Botswana is just one out of hundreds of nations and health systems trying to catch up with the trend-setters of the high income world. Of all the places I have been, I think Botswana has a blueprint that is the most adept at bridging the gap. They made the right investments twenty years ago developing world class individuals, and it’s that investment in people and education that I think brings about the next wave of overhauls. Yes there will be a drain, that is inevitable, but as economic conditions continue to improve, the inescapable pull of family and heritage will bring back enough. It’s really the nation that has to develop first in order for the health system to follow, and not the other way around. I have seen the reverse approach in the refugee camp in Uganda, where building from the periphery inwards had me rolling a boulder up a mountain. Botswana now has money, educated people, great doctors, but a flawed system. One has to hope and believe that the presence of smart people and resources will change the system via the passage of time and the inertia of growth. 

A crucial element for Princess Marina has been the development of training programs in part with the help of foreign investment. Out of sheer luck I got invited to the departure ceremony for the director of the Botswana UPenn partnership, who was leaving for a new post after several years at the helm. There was a large gala at an event centre in the city, with guests of honour including former hospital directors, the head of global health at Upenn, and the US ambassador to Botswana. It was only during the speech by the US ambassador that I appreciated the scale of this partnership. How better to overhaul a health system than to call on the might of Uncle Sam? The cynic in me appreciated the political motivations for the US government latching a foothold in the region neighbouring and rival to South Africa with its known ties to Russia and China. This all made me again realise that as one person, I am such a small speck against this massive world of competing interests, political history, and large machinations that are hard to influence.

So, I ask myself, what is the recipe for change? Is it me, Juan, healing-handed paladin jumping into jungles, concrete and tropical, in the darkest politically unstable corners of the world trying to help the sick and suffering? Is it Dr. Lopez Tiboni, medical educator, bringing new tools and skills to physicians with razor thin resources? Is it the NGO of your choosing, aid-delivering a marginalised population into better health with the hopes of local forces gaining aptitude to take the reins someday? Or is it Penn Global Health, a marriage to a large scale institution with the backing to overhaul frameworks? Where a health system falls in its own developmental journey might also alter where along that spectrum the most appropriate initial steps are. I ask myself this now more than ever as I look ahead to the culmination of my specialist training in the US and fall into the abyss of no signpost of where to take my journey next.

As for what actually comes next, I am going to try my best to live 12 months at a time. This series was written in March 2024. My residency finished over the summer and I took a month to study for board exams in late August. After securing board certification in the US, I’ll embark on a few different capacity building missions until December of this year. As for what comes next in January, I applied for the Red Cross, Doctors without Borders, and several other larger scale NGOs. I reached back out to Floating Doctors to see if they’ll take me back on the condition that I can make time for other projects. If the savings start to dry up faster than expected, I’ll have board certification in both the US and Canada and the possibility of short-term locums to keep the wallet happy. If this leads to a sustainable career in the space, great. If it doesn’t, I spent a few years doing some cool things and I can always pivot back to the high income world; I already have some ideas for fellowship pathways willing to indulge my big dreams. Truth is, I am not sure where exactly I am going, and at times it frightens me. That’s the beauty in life though. If my goals don’t scare me, I am doing this wrong.

As always, if you are still reading, I thank you. Your support keeps me going. I hope that you have found something of value in these words. Until next time.

Regards,

Juan