“We have to keep fighting to make improvements. Some people give up, but if we give up, then we have nothing. Our own family members will end up in this system.” — Dr.Macheng
When I first arrived in Botswana to take care of cancer patients, I knew I could handle it…
I previously spent a year running a small chemotherapy clinic in Lilongwe, Malawi, which is a much poorer country with even fewer resources. I was also fresh out of hematology/oncology fellowship training, which included my continuity clinic at the Veteran Affairs Hospital in Durham, North Carolina; I was used to getting things done without much help. However, like Forrest Gump (and his mother) used to say, life is like a box of chocolates—you never know what you’re going to get. I’d say this describes oncology in Botswana pretty well, although the surprises are usually not as nice as a caramel truffle.
I spend most of my time at Princess Marina Hospital (PMH), the public government-run hospital with over 500 beds in the capital city of Gaborone, Botswana. Although Botswana has a stronger economy and more resources than many countries in Africa, the public healthcare system still suffers tremendous limitations. PMH does have a dedicated oncology ward with about 12 beds (not counting the occasional mattress that turns up on the floor). There is also a small room for seeing clinic patients, and another small room for chemotherapy administration. Counting myself, there are currently three fully trained oncologists working at PMH. Dr.Chiyapo is a Motswana (native of Botswana) who was dual trained in medical oncology and radiation oncology, but not hematology. Dr.Mohammed is an oncologist from India who came to work in Botswana as part of a physician contract service paid by Botswana’s government. Dr. Gaolebale is a Motswana palliative care specialist who trained in Ireland and spends most of her time in the oncology department. We also have three medical officers in the oncology ward—Dr. Zola, Dr. Tieng’o, and Dr.Macheng, who underwent post-medical school training but have not completed specialty training in oncology. Only one nurse in the entire unit has had formal oncology nursing training in South Africa; others have learned about chemotherapy on the job.
The first week I arrived, the roof of the oncology ward collapsed—not a good way to start! We temporarily moved to another ward of the hospital, and had to move our clinic to the tiniest room I’ve ever seen—smaller than most closets. I can handle a lot of discomfort, but sitting in that cramped room all day, in sweltering heat with a broken air conditioner, seeing 30-40 patients in a row without a break definitely tested my patience. We have no patient records kept in the hospital (the patients take their records home with them) so I can’t prepare in advance for the cancers that I will see each day. While I know many of the standard treatments for individual tumor types, often the recommended first line drugs are not available in our pharmacy, so I’ll have to look up alternative or older regimens. An additional challenge is the language barrier. While English is supposed to be a required part of primary school education (in addition to the native language, Setswana), most patients speak it poorly or not at all. Since I don’t have a dedicated nurse available in clinic, sometimes if the patient doesn’t have an English-speaking relative or friend, we’re unable to understand each other. Often the research assistants helping with the Botswana Prospective Cancer Cohort study (run by the Botswana Harvard AIDS Institute) have to help me out. Also, with the lack of a nurse available for clinic, there’s no one available to take vital signs or properly triage patients. When patients arrive, they’re given a sticker with a number on it, and they sit in a line waiting their turn—first come, first served. Some patients arrive as early as 4 or 5 am to be first in line for a clinic that typically starts at 8 am. Unfortunately sometimes a very sick patient will end up at the back of the line, suffering for hours until I get to him or her. In addition we suffer frequent drug shortages. For example, I’ll start a patient on the chemotherapy drug paclitaxel with the plan to give 6 doses (cycles) every 21 days. After the patient has received 2 cycles, we discover it’s out of stock, and have no idea when it will be back in stock. So we have to decide—do we ask the government to get the drug from the private sector, by filling out a request form? This also can take weeks or even months, delaying the patient’s treatment. Or should we switch the patient to another drug, which may not be as effective as paclitaxel, and may complicate our assessment of whether the treatment is working? These are the questions we oncologists at PMH often have to ask ourselves.
Thankfully the roof of the oncology ward has been fixed, although we still use that awful tiny room for clinic. All of the challenges I’ve described have remained, despite my efforts and others’ efforts to improve them. All we can do is manage the best we can under suboptimal conditions, while continuing to have meetings, write letters to the government, and pick our brains to fix the long list of problems. Despite all the frustrations and disappointments, though, most of our patients are truly gracious and understanding. I can’t imagine suffering advanced cancer (as well as the side effects of chemotherapy) and going through all that they go through—from the long travel times (often hundreds of kilometers), to the long waits while sitting on crowded wooden benches, to the delays in treatment due to drug shortages. Their strength and endurance inspire me every day. I just wish we could give them the full comfort and support that they deserve.