The HIV prevention campaign in Botswana is quite extensive. Every place you go there are signs, billboards, etc about HIV. The signs are much more explicit than education campaigns I have seen in the States. Here are just a few examples. The one above is part of the "break the chain" campaign. There are billboards all over the city, highways, etc that state "Who's in your sexual network?" Some also say "break the chain" others leave it up to the individual to make the connection.
This sign is in the Serowe town center, right next to the bar.
If you look closely, you will notice that the wall of the bar is covered in "lovers" ads (a condom company)
A condom dispenser outside one of the public bathrooms at a local restaurant.
Unfortunately they are usually empty.
Even the inside of the moving truck that moved my furniture to Serowe was coverred in HIV prevention ads. The one of the inside of the truck is hard to read but says "Think before you act. Be wise Condomise"
Truckers are one of the highest risk groups, so this seems like a good place for ads.
Ads like this one for the controversial circumcision campaign are all over the city on billboards and buses.
They are trying to push the idea of personal accountability
One of the local free testing centers in Serowe
Free condoms were sitting on the nightstand of the hotel where I stayed on my first outreach trip to Serowe.
All of these seem like good ideas. The unfortunate part is these campaigns are not working too well. Condom use is still at only around 60% (though I guess that is higher than it was at the beginning of the epidemic, it has not incresed in recent years) and the prevalence of HIV in Botswana has increased slightly in the last year (0.5%). It has decreased since the beginning of the epidemic but recently has gone up. Getting people to change their behaviors is probably the hardest task in public health, but at least they are trying. And putting ads in peoples' faces does force them to think and talk about HIV at least a little more than before.
Today is Botswana Day/Independence Day, 43 years since Botswana became an independent nation (luckily the diamonds were discovered after independence ;) So Happy Independence Botswana!
There were even peacocks on the grounds of the hotel!
This past Thursday and Friday I was lucky enough to be able to attend the AIDS Impact Conference in Gaborone. It was an international 4 day conference where doctors, psychologists, researchers, economists, etc presented their research on different aspects of HIV and AIDS. Much of the conference focused on the social and economic impact of AIDS. It was quite interesting. Though some was disturbing. For example, there was a study done in Botswana to see which groups were more likely to have multiple concurrent sexual partners. (Public education about reducing the number of sexual partners and "breaking the chain of HIV" is one of the major areas being targeted as a prevention strategy.) The study found that both women and men who were more educated and richer were more likely to have multiple concurrent sexual partners (defined as more 2 different people in the last month) when compared to their less educated poorer counterparts. This is a bit disheartening because one would think that those who are more educated about the risks might be more likely to avoid risky behaviors.
There was also a big discussion of the role of circumcision in prevention of HIV. Three different studies done in Africa have shown that circumcised males are less likely to contract HIV when compared to their uncircumcised counterparts. So there is now a big campaign in Botswana to circumcise men. The problem is that circumcision is not as effective as condoms and does not provide any reduction in risk of transmission to women. Some men after getting circumcised have a false sense of security and believe that they have a "natural condom." However, if circumcision provides some protection maybe it is better than nothing since condom usage is only around 60% (despite widespread campaigns - more on that in a later post). I find it to be a very interesting debate and can see both sides of the argument.
I attended a motivational interviewing workshop which will be quite handy (I hope) in trying to get through to teenagers. There was also much discussion on the economic aspects of the epidemic and how by focusing only on HIV we have neglected so many other things. On presenter told the story of people in Tanzania who after testing negative for HIV were upset. When asked why, they responded that they had no food and wished they were positive because HIV positive people were eligible for food baskets! What have we done? Unfortunately there was not as much about where to go from here as I would have liked, but on the whole a very enlightening two days. And there is hope from Thailand, with the first vaccine to show any benefit. Still a long way to go but progress!
Here are some random pictures of the last week.
Me and Julia in garden at the Serowe Hotel
Hanging out with some new Serowe friends
Me, Lincoln (Peace Corps volunteer), Shamu (medical officer from Zimbabwe), Joanna and Danny (doctors from Cuba), Louisa (doctor from Sierra Leone who has had a private practice in Serowe for many years) and Daniel (science teacher from Zimbabwe who studied in Cuba and has been teaching in Botswana for many years). Quite a diverse group!
This is a picture of a girl I met in the center of Serowe who came up to me and said that she wanted to be my friend. She said that she wanted to live in my house, I told her that was not going to happen. Then she begged me to take her picture and send it to my friends in the States. So here it is. (She is wearing an interesting shirt - not quite sure of the full meaning)
L'Shana Tova (Happy New Year) to all Jews reading this (and anyone else who wants to celebrate the Jewish New Year). I hope that this year brings much happiness, hope, wisdom, and change to all the corners of the earth!
This past week has been quite busy. I worked at 2 different hospitals and one local health clinic. The disparities in the care available to patients in the village compared to what is available in Gabarone are striking (not to mention when you compare it to The States!). Botswana actually has quite a good preventative care model in theory. Every village has some sort of health facility. The smallest villages have mobile health posts that are staffed once a week or so by a nurse who travels to the area and does his/her best to provide basic services. Larger areas have health clinics that are mostly staffed by nurses but medical officers visit about once/week. Then there are district hospitals that can provide basic hospitalizations and procedures like c-sections. Finally there are larger "referral" hospitals. The problem is staffing and transportation. The clinics are staffed largely by nurses who try their best and refer when things get more complex, but there are no x-rays or lab tests available at the clinics and getting patients to go to the hospital for these services or to be seen by a doctor is hard. Also when patients are very sick at the local clinics the transportation to the referral hospitals can take too long and many don't make it.
Even at the district hospitals resources are very scarce. When I was in Palapye (the town about 20 min from Serowe) last week I saw a 10 year old with asthma who was breathing 70 times/min and really struggling for every breath. She was in the "paediatric (they use the British spelling here) ward" which consisted of 2 small rooms (about the size of a standard single patient room in the states) each with 4 patients (one of the patients was sleeping on a mattress on the floor and all of the patients' mothers were with them - it was quite crowded. There was no oxygen in the room and there was no nebulizer machine to give her albuterol which she so despirately needed. As the "Paediatric Specialist" they wanted my advice. Well, I thought she needed albuterol, oxygen, steroids, IV fluids, maybe even intubation the way she was breathing, but what was available? The nurses were actually great once I explained that she was incredibly sick, but could get better with the right medications. They found an albuterol pump and even a spacer which had been used by another patient, but we cleaned it! One of them went and got an oxygen tank (of course, then we had to look for a face mask or nasal cannula - there were none to be found). After about an hour (during which the mother was giving the child 2 puffs of the inhaler every 15 mins) a nebulizer machine was found! We (atcually they) even figured out how to plug it into the wall socket without an adaptor (all the wall sockets here have 3 square plugs and all the appliances have 3 round ones or 2 long ones, so you always need an adaptor for everything. Unless you stick a pen into the top square plug and jam the two long ones into the bottom holes - or something like that - I use adaptors (don't worry mom and dad ;)). We did not have a face mask so we rigged up the albuterol, so that the mother could sit with it under the child's mouth. Then I suggested giving her IV fluids and a dose of magnesium. There is no way to drip fluids here, and magnesium is supposed to be a slow infusion over 15 min. So we calculted the amount, mixed it in a syringe and one of the nurses pushed in 1 ml every min for 15 min. I felt kind of like McIvor. But several hours later the patient was already sounding better and the next day she was home!
Not every story is as cheery, of course. In Palapye almost every child I saw in clinic on Wednesday had a detectable viral load. Basically when you are on treatment for HIV your viral load should be undectable. If it is detectable then usually you are not taking the medications or have developed resistance (most often from a previous episode of poor adherence). These children are largely failing because they are not taking the medications and mostly it is because they have no social supports. Many are orphans living with relatives or in homes for orphans and no one ensures that they take their medications every day. In Gabarone we have a psychologist and a social worker to help patients and families through these issues. In the smaller villages there is sometimes a social worker, but usually it is one or two people for the entire hospital and there is not much they can do to change the home situation for many of these children. Also in the district hospitals it is harder to get labs tests done and returned. Viral loads have to be sent out and resistance assays (tests to see which medications the patient has developed resistance to. We use this only when they are failing second line therapy to try and figure out a salvage regimen for them as third line) are taken to Gabarone one day a week. On Wednesday the CD4 machine was down so none of the labs were being drawn. All of this means that many of the children I saw had been failing for months and we were still unable to select a regimen that might work for them.
The local clinic was even harder. Basically the clinics are a collection of trailers. The Infectious Disease Clinic (aka the HIV clinic but no one wants to call it that) is usually the last trailer in the back of the clinic. Yesterday the one computer at the clinic (which provides lab results) was not working, so it was hard to figure out how to manage the patients with no results. There are no appointment times at any of these clinics so all the patients show up before 7:30 and try to be first. They end up spending all day waiting to see the doctor, then they have to wait in line again for a nurse to draw blood if they need it (to be sent to the hospital) and finally they have to go to the hospital to wait again in the pharmacy line and get thier ARV (anti-retroviral) medications. So a visit to the doctor is at least a one day affair - more if you wait until the next day to go and get your medications filled. It is no wonder that adherence is an issue. And despite all this the vast majority of people are incredibly adherent to their medications (studies have shown that people in Africa are more adherent than those in the States. I think it may be because everyone here knows someone who died of AIDS and they know that taking the medications is the only way to survive.)
These are some views of one of the local clinics. On the left is the waiting room with the 2 consulting rooms on either side. Picture this filled with 70+ people waiting to see the doctor! On the right is a bad picture of the trailers that make up the clinic. (I was trying to be inconspicuous)
I don't want this post to be a total downer so I thought I would end with a picture of the beautiful sunset that I can see from my house every night. The stars are also incredible.
And here's one of the horses that often hang out right in front of our gate. On some days there are donkeys too. I'm not sure who they belong to, but they seem to know thier way home at night.
Sorry for the random organization here but I can't figure out how to get them in a better order right now and internet cafe closes at 11:30 on Saturdays.....
My house in Serowe
There are 5 others just like in a row, I have the first one.
3 bedrooms, a bathroom, kitchen and living room,
quite spacious for one person (but plenty of rooms for visitors, hint, hint)
Classic bird on rhino picture
They were so intent on eating their grass, they did not seem to notice us even though we were about 10 feet away! A good thing since they can be dangerous if mad!
(Don't think this one needs a caption you all know what this is ;)
My living room
The kitchen. On the wall by the circuit board is the electricity unit. I have to go and buy a electricity for the month and then enter a code in the box, which then supplies electrcity for the alloted killowatt hours.
A sunset view of the village from the top of a hill near the town center.
It actually goes on for quite a distance.
Goats (and cows) are everywhere here. They are definitely free range! Here are some walking across the main road in the town center. Apparently they all belong to someone and they find their way back to their respective farms (I'm not sure how).
I have moved to the “village.” Serowe is a village of about 70,000 (a town by most US standards, but here they call pretty much everything that is not one of the two cities a village). As I mentioned previously, it was the home of the first ever president of Botswana and birthplace of the current president Ian Khama (the first president’s son). As such, it is a village that is well looked after which is probably one of the reasons that the large “referral” hospital was built here. You can see pictures and description of the hospital here.
I officially moved here last September 1st. It has been an adjustment. Gabarone is a large city with many restaurants, movie theaters, etc. In Serowe there is not as much of a recreational life. However, there are high quality supermarkets, plenty of furniture (I’m not sure who buys things there as furniture is pretty darn expensive) and clothing shops, gas stations, a few hotels with restaurants, and tons of bars. However, the internet infrastructure is lagging behind, there are many more dirt roads, there are many fewer foreigners, many more bugs and other critters, and very few doctors. I am trying to get internet set up in my house which has been a process. Though I live right next to the post office which has internet, (they even have an internet cafe but it closes at 4 pm), the Botswana Telecommunications Company says that all the lines are full (whatever that means) so there is no room for me to have a landline or internet. I am working on looking into cell phone based satellite internet options, but until then might be hard to get pictures on the blog (there are so many to upload but they will come with time ;) Despite the frustrations it feels good to finally fully unpack and feel more settled.
I am working at many different sites in the area. The hospital which is very nice, was built a bit outside of the main village and in a country where most people do not have cars this presents a challenge for the patients. Many of them are continuing to go to the smaller local health clinics for care as they are more convenient. Up until now, our program has provided support for two days each month to the main hospital’s clinic but we have not been helping at the smaller local sites. I will be trying to roll out the support. However, this is a challenge as there are no maps, no street names, and the clinics operate on a skeleton crew (often there is only a doctor once a week). With the help of some locals, I have located two of the clinics and though there was no doctor there when I found them last week; I now know which days doctors will be there. In addition to Serowe, I will also be working in two surrounding villages (Palaype (about 30 min away) and Mahalapye(about 1.5 hr away). Both of these villages have larger hospitals and surrounding clinics as well, so I will be trying to work out a schedule that can provide support to as many as possible.
The good news is that without internet or much nightlife, I have had plenty of time to study for the Boards. However, last Friday I did manage to meet up with Lincoln (a Peace Corps volunteer stationed in Serowe) and he gave me a great tour of the town and introduced me to the friends he has made in his year here. Many of his friends are from Britain and South Africa, so I got the beginning lesson on how to watch cricket (which was playing on the TV at the hotel restaurant/bar where we hung out). I’m afraid it will take many more lessons before I have any idea what is going on (as it is I was just starting to understand American football when I left the States). I have also made friends with some of the Cuban doctors here so there is a possibility of Salsa lessons and improving my Spanish….
Last Saturday (after I studied in the morning), Julia and Raheel came up from Gabs and we went to the Khama Rhino Sanctuary (only about 30 min from my new house) for the afternoon. It was incredible. The Sanctuary was set up in 1989 after it was recognized that the Rhino population in Botswana was becoming extinct. The first four rhinos arrived in 1993 and since then a few more have been relocated to the Sanctuary and many more have been born. There are now 34 white rhinos and 3 black rhinos. They roam in an area that is 4,300 hectares (10,625 acres) and some have been relocated to other national parks in Botswana as the land can only support about 40 or so. It has been quite a successful project and the rhinos continue to reproduce. At the Sanctuary one can drive around in his/her own car alone or with a guide or can go on a game drive. We elected to get a guide but take our own car so we would be free to spend as much time as we desired. Our guide “Mr. T.” was a wealth of knowledge and of course excellent at spotting the animals. We saw 12 of the white rhinos including 2 babies, giraffes, a zebra, wildebeest, kudu, springboks, ostriches, warthogs, and many different species of birds. The black rhinos did not feel like showing their faces but we got up close and personal with a few of the white rhinos. It was a great day and I know I will be back to visit many times in the future!
Today was my first Teen Club and it rocked! Teen Club is a chance for HIV positive teens ages 13-19 to get together each month. There are now Teen Clubs in four cities/towns in Botswana. The largest one is here in Gaborone with around 300 teens registered. On the average month about 120 show up! Since we have such a large group, the teens are divided into younger (13-15) and older (16-19) groups. This month the older teens got to learn hip hop dancing, while the younger group had a session on "love, sex, and dating." (Each month one of the groups does "life skills" sessions, while the other group does a fun activity and the following month the groups switch).
The day began at 8:30, as we gathered in the clinic parking lot for icebreakers. The fact that 120+ teenagers are willing to wake up early enough to be somewhere at 8:30 on a Saturday morning shows just how much Teen Club means to them (esp since some travel pretty far distances). The ice breakers were led by the excellent cadre of teen leaders (teens who have been elected to help to facilitate Teen Club, they also help with planning the activities, and many were counselors at Camp Hope this year. After the ice breakers the groups split up, with the older group going to a local school to learn hip hop and the younger group staying at the clinic.
I was one of the facilitators for the younger group. After an introduction, by the teen leaders, we split off into 6 small groups. I had a group of 11 (4 boys and 7 girls) and a teen leader as a co-facilitator. Thank god for my teen leader, who was awesome! Many of the teens have a hard time understanding complex concepts in English and feel more comfortable speaking about tough issues in Setswana. So she was invaluable at leading the group and bridging the language divide. The activity was very well planned out and we facilitators had guides to help us lead the session. We began with a map of the city and had the teens point out areas in the city where boys and girls meet. We talked about what kinds of activities teens do in these areas and which ones were healthy or unhealthy. In a country where billboards proclaim "Who's in your sexual network?" and where condoms are everywhere, (more on that in a later post), these teens have gotten a lot of exposure to messages about the ABCs (Abstinence, Be Faithful, Condomize). So they were pretty quick to point out that unhealthy activities might include unprotected sex which could lead to teenage pregnancy, STIs (sexually transmitted infections), and "spreading the virus."
Next we divided the girls and the boys and had them come up with the qualities that they would want in a boyfriend/girlfriend and then husband/wife. The girls wanted a boyfriend/husband with "inner beauty," "one who respected them," "one who slept at home at night," (a reference to the practice of men having a "large house" and "small houses") "one who was trustworthy, caring, and a good listener." The boys wanted a girlfriend/wife who was smart ("able to help them with homework"), playful, good at communicating, had good ideas, was a good cook, a good mother, did not cheat, was not lazy, and respectful. We then spent some time talking about gender roles. For example, if husbands should be expected to help out with taking care of the children. Most girls said "well they won't even know how to change a nappy" (diaper) and the boys said "it depends on if I have been at work all day." The teen leader and I talked a little about how roles might need to be shared esp. if both partners were working outside the home (which is pretty common here).
We then had an exercise where we read statements and the teens had to move to one side of the room or the other to indicate whether they agreed or disagreed with the statement. We began with "a boy should always pay for food on dates," to which only one boy agreed saying that "the man" should pay while everyone else said it should be more equal. We moved into more difficult questions the hardest being "If a married couple of two HIV positive people wants to have a child it is okay for them to have unprotected sex." In my group everyone disagreed with this. One girl explained that each person has a different HIV virus so you can still pass it to the other partner even if you are both positive (very advanced understanding esp. for a 14 yr old). Others said that the couple should adopt if they want to have children. Obviously the powerful message of the perils of unprotected sex has reached these teens, lets just hope they practice what they preach. At the end we joined all the other groups for a discussion of the activity. We talked more in depth about this last difficult question and explained that it would be possible, under special circumstances, for an HIV positive couple to have an HIV-negative child, but it would be something that should be discussed with a doctor.
The activity went incredibly well. The teens were very engaged, and though some spoke up more than others, all participated. Teen Club is their one opportunity to be completely open about their HIV status and feelings surrounding it. Most don't feel comfortable talking about it with any of their friends, including romantic partners, and live very secretive lives. The burden of constantly keeping a secret can be very troublesome, so it is great that they have Teen Club where at least once a month they can be open and honest. It did strike me though that we completely left out any mention of homosexuality. In a country where homosexuality is illegal, it is a very taboo subject and one that unfortunately I do not think Teen Club is ready to tackle. However, I can't help but wonder and worry for the teens who have feelings for people of the same sex. They are already marginalized by their HIV status and being gay must be an incredibly hard extra burden. I will have to do more investigation on this to find a way to let teens here know they can be open about all kinds of feelings with me.
After the session wrap-up all the teens gathered for lunch and to get transport money (the Teen Club pays for their transport to and from the club to make it more accessible). The Teen Club provides an incredibly valuable role in these teenagers life. It runs largely on volunteers, but we do have to provide lunch and transport money. So you may have noticed that I have added a "button" to this blog on the right hand side of the page. It says "donate now." If you click on this button you will transported to the Texas Children's Hospital website where you can make a secure, tax deducible donation to Teen Club. This money also gets used to support Camp Hope. Every dollar makes a huge difference, as for only $60 you can pay for the transport of 1 teen to Teen Club events every month for a YEAR! If you want to read more about how much things cost look here: www.botswanateenclub.wordpress.com/donations/ So next time you are looking for a gift for someone, think about making a donation to Teen Club in their honor!
Sorry for those who are not medical, but I will try to explain some of the more medical terms....
Each day at the Botswana-Baylor Center of Clinical Excellence (or the COE, as we call it) begins at 7:30 with a prayer. There are no appointment times; patients are just given a day to return and most show up around 7:30 (which often means they have gotten up hours earlier to travel from their village to the city). The clinic staff (nurses, receptionists, pharmacy techs, translators, social workers, medical assistants, janitorial staff, doctors, etc.) gathers in the lobby, facing the patients, and begins to sing. They sound like a professional choir, (for all those concerned, I sing very quietly or mouth the words to the songs I know). Usually the songs include "Kumbaya my lord," some songs about Jesus, and songs in Setswana. At the end, there is a prayer in Setswana. It is a wonderful way to start the day with the songs filling the lobby, the building, and spilling out into the parking lot - giving hope and offering support to all of our patients.
Around 7:45 or 8 we see the first patients. Today I saw some great success stories and some challenges. The first patient I saw was a 16 yr old boy who came alone. He was very energetic and doing excellent with taking all of his meds = 100% adherence! He stopped in the middle of the visit to return a text message, and when we were done stood in the hallway with his cell phone on speaker so everyone could see how popular he was. When I asked if he would be joining us for Teen Club this Saturday he said maybe but he had a number of things to do and wasn't sure if it would fit into his busy schedule. His viral load is undetectable and his CD4 (cells that fight infection) are as high as person without HIV. All that has been achieved, and he is still on first line therapy (meaning he has never become resistant to his medications - which usually happens when patients don't take their meds).
Then there was an 8 yr old boy who had been doing very well on therapy for serveral years until 2006 when his mother stopped bringing him to clinic, and hence stopped giving him his meds. The clinic staff tried to track him down, but to no avail. He returned last month because he had lost a lot of weight (he weight was that of a 5 yr old, as was his height), had a chronic cough, night sweats, and fever. He was admitted to the hospital and started on treatment for tuberculosis. His mother, who also has HIV, had been faithfully taking her medicine (which she got at a different clinic), but had not brought him to see a doctor for three years. She said it was because she did not have money for transport. Today she brought back only one of the medications he had been given in July (mutivitamans and cotrimoxizole (or bactrim for those in the states) to prevent infection in those not on treatment for HIV). His adherence on that was 76% which is not sufficient for being successful on ARVs (antiretrovirals). Clinically he needs to start on medications, but we can't start medications if he won't take them, because he will develop resistance and be out of options. Luckily we have an "in-reach" team and the charge nurse had a long talk with mom. The team will go out to the house on Friday and assess the situation, do some education, and determine if the family can qualify for transportation assistance. Hopefully, we will see him again in 2 weeks. Hopefully by then, he and his mom will be ready to commit to treatment.
And then there was the 10 yr old severely developmental delayed boy who lives in an orphanage (both of his parents died many years ago, presumably from AIDS). One might think that living in an orphanage would be good as far as adherence since he is taken care of by "professionals," or at least people who have received more training than most. However, often the orphanages are understaffed and there are so many changes of caregivers that they forget to give the children their meds. This child's viral load (amount of HIV in his body) was sky high (it has never been suppressed). He was on "salvage" therapy - basically he has developed resistance to many of the medications available in Botswana. So we send a resistance assay (a test to determine which drugs his HIV is resistant to and which are still options). This test is done routinely in the states, even on patients who are on first line therapy. But here we reserve it only for the most challenging patients, and we are lucky to be in one of the few countries in Sub-Saharan Africa where the test can be relatively easily done (though it takes at least a month). He was again failing the therapy that had been created based on the last assay, so we had no choice but to send another resistance assay, stop all medications, and once again send the in-reach team to the orphanage to see if they could figure out the adherence problems.
Those were just 3 of the 10 patients I saw in the morning. We finished at 1:30; I took a small break to eat a PB+J sandwich and made my way over to the main hospital for "general peds clinic." Since there aren't many pediatricians or even family doctors in this country, most patients are seen at local clinics by nurse prescribers (kind of like Nurse Practitioners, only with less training) or medical officers (people who have completed medical school and one year of general internship (a little of each specialty) and then go into practice.) When there is a pediatric question, they are referred to the nearest pediatrician. As there are not any pediatric neurologists, nephrologists (kidney doctors), cardiologists, etc in the country we "general pediatricians" become instantly upgraded. I saw several children with Cerebral Palsy and Epilepsy and managed their seizure medications. I saw a child with steroid resistant nephrotic syndrome and started her back on cyclophosphamide (sorry non medical people - can't really explain all that). I saw children with severe developmental delay and speech problems and sent them for hearing tests and speech therapy (luckily we do have speech therapy). And even one that I really knew how to tackle - a 3 week old with breast buds which were already getting smaller = normal! Basically in one day I have been upgraded from a general pediatrician just out of residency to an HIV specialist, pediatric neurologist, pediatric nephrologist, and developmental pediatrician (to name a few). Luckily I have some of the more seasoned PAC doctors around to offer consults, but in an environment without as many labs, x-rays, and other diagnostic tests as we are used to; we are often treating blindly and following closely.
If you are still reading, and wondering how patients pay for all of this, you will be surprised to know that it is completely FREE! The Government of Botswana (with revenue from the diamond mines (that they were smart enough to own), 10% sales tax, and 25% income tax on the weathly, pays for it all!. This includes doctors' visits, meds, tests, and even transport to and treatment in South Africa for things, like cardiac surgery, which are not yet available here. I say it is worth it! And it is certainly nice not to have to fill out insurance pre-authorization forms, billing sheets, or check insurance formularies. (Yes, you do have to check the Botswana drug list, but it is just one list for everyone and a surprisingly complete one!)
I saw a very enlightening piece on this theme from PBS (one place that allows you to watch their videos outside the US - boo to netflix, hulu, and amazon).
I recommend it to you all: http://www.pbs.org/moyers/journal/07312009/watch.html
I'm a pediatrician who spent 2 years in Botswana with the Pediatric AIDS Corps. I have now moved to Cape Town, South Africa to work for an organization called South to South
