Hello from Gabarone,
I am now half way into my trip and I thought this might be a good time to sit and reflect on the things I have learned/experienced so far. The major lesson I learned is that more questions arise than there were answers. The choice to come Botswana stemmed from an already established collaboration between the Oncology department at MGH and two hospitals in the city of Gaborone (one public/government run) and one private which services government insured patients for certain aspects of care mainly with regards to oncology. The objectives were a few fold help establish breast cancer guidelines in hopes of standardizing treatment of breast cancer patients. Additionally, I hoped to assist with setting up a multi disciplinary breast clinic to make the transition for patient much easier.
Both have come with challenges as well as some progress. In trying to adapt the breast cancer guidelines used in the US, I had to get input from physicians who practice here in Botswana. Immediately you realize that cancer in the US is very different from Cancer in Botswana. For example where as we have screening guidelines and yearly mammography to detect early and occult malignancies, one of the physician’s quotes that 99% of breast cancer patients that they encounter self palpated a mass. This essentially means that the breast cancer is locally advanced and diagnosed at a much later stage. This also means that things like breast conserving surgeries which is a viable option in the US is not an option in Botswana i.e women who come to attention for management of breast cancer, get mastectomies. So the questions: why are women diagnosed so late? Why is there no capacity for screening, is it an acceptable fact young women are dying of potentially curable malignancies? In a country where breast are associated with femininity, is late stage disease resulting in mastectomies the best that can be done? There are so many questions…
Back to the guidelines, even though currently the guidelines are a skeleton compared to the one used in the US, it leaves a lot of room for improvement, which is a major positive. Also all the physicians were on board that these guidelines were in deed important and were mostly willing to contribute from their perspectives so that care can be standardized.
With regard to the multi disciplinary clinic, the major limitation currently is finding an adequate space that would allow all the participating physicians to evaluate the patients’ together. Also hiring a nurse that could staff that clinic full time has been a challenge. Even though the government has the capacity, I have learned is that cancer is not quite as high a priority as infectious disease for example. The nation wide campaign against HIV and TB has been remarkable partly because the percentages of both are so high and there were enough interested parties to highlight the toll these diseases were taking on the population. Being an optimist though, I think there are enough interested parties that want to change the thinking about cancer; I believe the break through is just around the corner, at least I hope.
In terms of helping the to stream line the process for patients, I am setting up a meeting with a physician who works with the ministry of health to discuss efforts to educate local providers and health care workers to recognize warning signs and symptoms and also to focus on age appropriate screening as part of their general check up, stayed tuned for the results of that meeting on the next post.