“HIV crosses every discipline you can think of,” from legal rights to business productivity, says Dr. Harvey Friedman, director of the Penn-Bostwana program. “I thought it was very important to open it up to as much of the University as possible. It just expands the impact of what Penn can do there.”

Last summer Provost Ron Daniels traveled with a Penn team to Bostwana and found the program to be “a wonderful exemplar of so many things we’re trying to achieve at Penn,” from international engagement to bridging theory and practice. “We saw there were lots of opportunities for us to harness the rich array of intellectual resources at Penn in collaboration with the University of Botswana around the multidimensional challenges of AIDS,” he says.

Dr. Musa Dube, an associate professor of theology and religious studies at UB who is interested in how gender relates to HIV/AIDS, is looking forward to a widespread collaboration with Penn and a related NIH grant that would free up some of her colleagues from their heavy teaching loads and give “a lot of time and space to do research,” she says, adding: “As we exchange ideas, hopefully we will be able to inject [Penn] with the diversity of an African perspective,” she says. “We’re [also] hoping to learn from their scholars and institutions,” from Penn’s Center for AIDS Research and medical school to its gender-studies programs.

 

Dr. Stephen Gluckman, clinical director of the Penn-Botswana program, has two kinds of patients back in Philadelphia: those who get a bit frustrated that he’s gone five months out of the year (and who often find another M.D.) and those who think his overseas work on infectious diseases is “pretty cool,” he says. Some of the latter make donations to the program. One patient has even bought a house in Gaborone to serve as living quarters for some of its participants.

Gluckman’s involvement, and the program itself, began in 2001 with a request for help from the African Comprehensive HIV/AIDS Partnership. The Merck Foundation, the Bill and Melinda Gates Foundation, and the government of Botswana had formed a partnership to provide antiretroviral drugs to the country’s infected citizens. Could Penn send some doctors to train medical professionals in using the medication?

Friedman, who is chief of the infectious-diseases division at the Hospital of the University of Pennsylvania, called upon four doctors, including Gluckman, a professor of medicine and the division’s director of clinical services.

“There wasn’t any concept at the time that Penn’s involvement would be ongoing,” says Gluckman. When he first went to Botswana, he recalls, “It was meeting after meeting, and sort of boring. So I asked, ‘Where is the local hospital?’ They pointed me to Princess Marina, and I went over there and sat in a couple of conferences and asked if I could do rounds with them. That was a three-month stint, and by the end of it, I had my own [medical] service.”

Gluckman thought that Botswana would be a good place for Penn medical students and residents to get some overseas experience. He and Friedman got seed money from the medical school and HUP to launch a small program. “Everything expanded rather dramatically from there.”

The inpatient wards of Princess Marina were, and are, a far cry from HUP. “When you do rounds in the hospital most days, they are over-capacity, with patients lying on the floor on mattresses,” says Friedman, who does most of the administrative work and program-building back in Philadelphia while Gluckman works on the wards in Botswana. “There’s TB in many patients, and there is no isolation ward. And they might have sinks on each ward, but there’s no soap. And if there’s soap, there are no towels.”

“When we got there, there was no teaching in the hospital at all,” Gluckman adds. “There was no signing out when people left, no handing off of patients, and essentially no coverage [by doctors] on the weekends.”

Change has been slow: It happens during the morning meeting, or grand rounds, when all the doctors gather to talk about newly admitted patients and interesting cases. It happens in the oupatient HIV clinic and in the wards, where medical teams of Penn doctors and their local counterparts work together to treat conditions ranging from hypertension to tuberculosis. It happens in four weekly educational conferences set up by Penn.

“Most doctors there are just hired by the government and they have a contract to work,” Gluckman says. “There is nothing in their contracts that says they have to care, or to read about medicine, and it has taken a fair amount [of effort] to get them to buy into why all that stuff is good. [But] they have bought into it, and that’s been really gratifying—in many ways more so than the individual patient” encounters.

“It’s a remarkable impact that, in a very quiet way, Penn has had,” says Provost Daniels. “What Penn has done is place its medical personnel into the hospital, and of course that had an immediate effect on the quality of patient care, but more than that, it’s had a broad effect on raising the standards of professional excellence in the hospital.”

The differences are amazing, adds Dr. Scott Halpern Gr’02 GM’03 M’03, a fellow in pulmonary and critical care who went to PMH as a fourth-year medical student in 2001, and then as a senior resident in 2005. “We went from a system in which there was no such thing as a computer and very few drugs available to treat common things, let alone almost no drugs to treat HIV, to lab tests ordered on the computer and patients tracked on the computer and a state-run, reasonably widely available antiretroviral drug program. The one constant was the overwhelming illness seen in the inpatients. It makes what we do in America seem tame by comparison.”

COVER STORY :
Prognosis Botswana By Susan Frith
Photography by Rick Cushman

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The Penn-Botswana program has four components:

Clinical care and education. Penn has signed agreements with the Ministry of Health to take part in medical care and educational programs at Princess Marina Hospital (PMH) and Nyangabgwe Referral Center in Francistown, and—on a rotating basis—nine surrounding district hospitals. A federal grant through the President’s Emergency Plan for AIDS Relief supports six full-time Penn doctors in the country. The University is also developing a clinic for HIV patients with opportunistic infections and metabolic problems.

Global health experience. Over the past two years, more than 100 Penn medical students and residents have worked in the hospital wards of Botswana. This academic year about 35 fourth-year medical students and a dozen or more infectious-disease fellows and residents in internal medicine and specialties such as dermatology and emergency medicine, will do electives there.

Research: Through the Center for AIDS Research, Penn and Batswana researchers are studying, among other issues, meningitis, tuberculosis, and the treatment success and failure of patients on antiretroviral drugs. (People from Botswana are called Batswana, not Botswanans. One person from Botswana is Motswana.)

Collaborations: This fall Penn signed an agreement with the University of Botswana (UB) to create collaborations in medicine, nursing, and other disciplines. UB is forming Botswana’s first medical school, and as part of that effort, Penn will develop a curriculum for a rotating internship at the country’s teaching hospitals as well as post-graduate residency programs in internal medicine and other specialties. In addition, Wharton’s Societal Wealth Generation Program has launched a health-care study in the country to reduce the effects of HIV on its workforce; the nursing school is sending professors over to teach the “best practices” of their profession; and researchers from the nursing and Annenberg schools are looking for ways to reduce the risk of HIV transmission among Batswana adolescents. This spring, Penn undergraduates are taking part in the University’s first semester-abroad experience in Botswana.

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©2007 The Pennsylvania Gazette
Last modified 03/01/07