Penn medical students and residents planning to work in Botswana can download a handbook that outlines protocols for grand rounds, polite greetings in the local Setswana language, and even good places to eat. But one thing it can’t prepare them for are the deaths they will witness. “One of the things they’re going to see, guaranteed, every day is people dying of things there that they won’t die of here,” Gluckman says.

Dr. Jason Kessler, who came to Botswana as a clinical instructor shortly after finishing his residency at Penn and most recently headed up Penn’s HIV-TB co-infection program there, says he was shocked at first by the level of illness he encountered.

“One of my earliest experiences here in Botswana that stands out in my mind involved a young man in his early twenties. He was admitted to the hospital with signs of meningoencephalitis (infection of the brain and its surrounding tissues) and was begun on antibiotics for a presumed bacterial infection.

“This unfortunate young man was delirious, feverish, and his family had brought him to the hospital after his condition continued to deteriorate at home,” Kessler recalls. He was also found to be HIV-positive, though it was not clear whether the two conditions were linked.

After seeming to stabilize over the next day or so, the patient fell unconscious. “We tried desperately to initiate the measures I was used to as a trainee in the U.S.—paging doctors, starting IVs, resuscitation—but as we continued our efforts, which seemed to be getting nowhere, the patient began groaning,” Kessler says. “Loud, awful groans that reverberated through the ward, causing all the [visiting] families in the area to turn and watch us as we struggled. It wasn’t more than a minute or so later that the patient arrested and died in front of us all.

“The suddenness and the fierceness of death stunned and shocked me,” he says. “I don’t think I had really witnessed anyone, especially someone so young, die in my presence. Of course, I had been present at ‘codes’ during residency but that experience was more similar to a drill—a bunch of people in a room carrying out different tasks in a generally organized fashion. The patient seemed almost irrelevant and completely dehumanized. This was something so completely different and disturbing. It opened my eyes to the nature of illness here—people my age or even younger dying every day, and my limits as a doctor to help many of them.”

Halpern remembers a 17-year-old boy who couldn’t walk around, or even breathe easily, because rheumatic heart disease had destroyed his aortic valve, leading to “horrendous heart failure.” In the United States the valve could have been fixed surgically, but there were no specialists in Botswana to do this. “We worked for the better part of 2 1/2 weeks to try to convince the government to issue him a passport so we could transport him to South Africa, where there are cardiac surgeons,” Halpern says. “Ultimately we could not get him that passport in time. He literally died due to the lack of a passport.” Now it has become much more routine to transfer patients who need specialized care, though a larger goal is to bring those specialties to Botswana itself.

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

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(Left) Medical students accompany Gluckman on rounds, when newly admitted patients and unusual cases are discussed. Gluckman spends five months out of the year in Botswana.

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