Flying Outreach

Since Botswana is so spread out and the majority of the country lives on the Eastern border, there are many parts of the country which are extremely rural these areas have few doctors and usually no specialists.  So a local NGO has organized charter flights to some of the sites which are the farthest from Gaborone.  They fly the plane above which seats 8 (9 if some one sits on top of the area that can act as a toilet in extreme emergencies) plus the 2 pilots.  Each Tuesday it flies specialists from Gaborone to a different area of the country (repeating on a monthly basis to cover 4 areas with monthly visits).  There is always a Botswana/Baylor Pediatric HIV specialist and a doctor from the Botswana/U. Penn program who can help consult on more difficult medicine patients.  Depending on the site there are other specialists from the government hospital as well (including orthopedic surgeons, nutritionists, and even an ultrasound tech who brings a portable ultrasound machine).  Last Tuesday, we (A family doctor from Botswana/Upenn, a TB specialist from Botswana/UPenn, a diabetes nurse from the Gaborone govt hospital, and I) went to Ghanzi which is all the way on the Western boarder of Botswana.  Since the plane is small, it is more subject to the winds and since they were strong on Tuesday it took us almost 2 hours (rather than 1.5hr) to fly from Gaborone to Ghanzi.  The pilots are excellent though, so it was really a smooth flight.   We arrived at the Ghanzi "airport" which is really a collection of small trailers and buildings and there was no one in sight.    

The Passenger waiting room is never really used, so they have filled it with a small collection of artwork, more like a museum than an airport waiting room and aptly called the "passenger terminal shed."

After about 15 min a van from the hospital came to drive us the 10 mins from the airport to the hospital.  The hospital is situated on the outskirts of town (so that they could make it nice and big).  Which makes it hard for people from the town to get to it without transport (much like Serowe).  However, it does look nice.

There is really nothing right around the hospital just a lot of empty land

  We finally arrived at the hospital around 10:30 and I headed to the HIV clinic to begin seeing patients.  I worked with a nurse prescriber to see 10 HIV positive children many of whom were either failing treatment or had multiple medical problems. One 17 yr old girl had the worst case of oral warts I have seen.  Warts (caused by the virus HPV) are more common in immunocompromised patients, because they are unable to fight the virus and thus it spreads unabated.  She had warts covering both her upper and lower lips and her tongue.  Unfortunately there are not many treatment options available other that ARVs (antiretrovirals) to boost the immune system and enable it to fight the HPV.  However, you can imagine the distress that this would cause a teenager (she has been dealing with it for years) and since it takes a long time to improve, she keeps stopping her ARVs because she feels it is not getting better.  I spent a lot of time trying to convince her to stick with the treatment and hopefully she will stick it out this time.

We saw a 1yr 8 mth old baby who was still not walking, not talking and had just started to attempt to crawl (a skill normally obtained around 8 mths of age).  And a nine year old who could not hear well, had never really talked, and had never attended school.  These children are the hardest, because there are no services available for them out in Ghanzi.  There are only a few places in the country where hearing can be tested (critical in both these cases) and they are all 100s of kilometers away.  There is only one speech therapist in the country and she is in Gaborone.  And the only special education schools that I know of are in the two bigger cities (Gaborone and Francistown).  For the baby we were able to refer her to the physical therapist (luckily there is one in Ghanzi) and for both I tried to encourage their mothers to take them to the nearest place where their hearing can be tested.  The nurse also informed me that there are some times when the ENT doctors come on the flights and might be able to do hearing testing then, he was going to investigate and then let the mothers know when to come back.  But without special education and lots of therapy, and possibly hearing aids, these children will never reach their full potential, and even if they were in Gaborone these would be really hard to come by.    

Another complicating factor is that a fair number of the patients in Ghanzi are San (a tribe that lives in the Kalahari desert and many of whom were resettled into towns by the Botswana government when they made the Kalahari protected land, much like what happened to Native Americans in the US).  Therefore many do not speak Setswana (much less English), so communication between health care workers and patients is especially difficult.  Also they have a lot of traditional medicine practices and it has sometimes been a challenge to get them to take ARVs.  Only one of the patients whom we saw on Tuesday was San and her mother spoke very good Setswana and was committed to the treatment, so it was not really an issue this visit.

After seeing all the children in the HIV clinic, I went to the pediatric inpatient wards to see if they had any cases they needed reviewed.  The medical officer was not around, but the nurses asked me to see a 3 yr old severely malnourished child who was not walking or talking.  There is a strong possibility that the child has HIV and I recommended an HIV test (something that really should be routine on every inpatient admission in this country, but seems to be missed a lot of the time despite our nagging).  If the child is positive, ARVs will likely help.  Otherwise we will be stuck with many of the same issues faced by the other developmentally delayed children, lack of appropriate special services.  It is frustrating to feel unable to provide any real solutions. 

We headed back to the Ghanzi airport at 5 pm (eating a lunch of crackers, granola bars, and oranges in the car) for our almost 2 hour flight home, feeling that we had done some education and treatment, but still there was so much left untouched.