With a significant portion of Botswana’s adult population infected with HIV, the virus carries an enormous economic and social cost. “That’s the economically active age group, and the sicker they get, the more debilitated industry becomes,” says Jim Thompson, associate director of Wharton Entrepreneurial Programs and co-creator with Management Professor Ian MacMillan of the school’s Societal Wealth Generation Program (SWGP). “We started to think about how we might intervene with [information technology] or other alternative assets and demonstrate there’s a way to keep the workforce more vital and extend lives at a lower cost.“

The SWGP is working with a private medical practice in Botswana to see if cellular-phone text-message reminders will improve the rate at which HIV patients refill prescriptions, visit physicians, and reduce their viral loads. The technology would help address the country’s current shortage of doctors and nurses, freeing up medical workers to concentrate on the sickest patients, Thompson says.

“If we’re successful, we’re hoping we could expand this to cover malaria and TB and other critical diseases, and [that] somebody else might be able to use this in other parts of the world.”

Expanding on the potential of information technology, Thompson envisions the development of an electronic health record with built-in treatment protocols that could provide enough support for the front-line medical workers, such as certified nurses, to care for patients who are in stable condition or who have just been diagnosed with HIV. When necessary, Thompson says, a physician could look at the patient’s electronic file and say, “‘I think that’s enough information. Here’s what I’d recommend,’ or ‘Here’s a referral. This patient needs to come in.’”

In addition, Penn’s nursing school will be working to improve “care at the bedside” in Botswana. Beginning this summer, small teams of nurses with expertise in leadership, oncology, and trauma nursing will be sent for 12-week stretches to train local nurses and help them improve patient care, according to Dr. Victoria Rich, chief nurse executive for The Penn Medical Center and assistant dean for clinical practice at Penn Nursing.

It’s been almost three decades since Rich herself was involved in clinical nursing practice. But on a visit to PMH last August, she was saddened to see that she could step into a ward there and still know what to do. “That’s how behind the times they are,” she says, noting gaps in infection control, supplies management, and other processes that are taken for granted in U.S. hospitals.

“There’s one blood-pressure cuff for 20 patients, no IV pumps, and no infrastructures to see if they need supplies and equipment. On a 30-bed unit they’ll have 60 patients, and there will be people lying in a sleeping bag or on a blanket on the floor,” she says. “But the people want to learn … and to take care of their own.” And “their validation of human existence is at a level much higher than I think we have in the United States: their sense of not being prejudicial, just making do with such minimal things, but making do in a dignified way.”


For an hour each afternoon at PMH, the visitors crowd in and most medical work comes to a halt as family members stand elbow to elbow, bringing food, prayers, and encouragement to the patients. “It’s just incredible devotion—devotion we don’t always see here” in the U.S., says Scott Halpern.

Dube has begun to see something else in the interactions of people in her country. “I feel like we’ve been through it all [with HIV] and we’ve reached a point of acceptance, of living in hope,” Dube says. “There are two phrases I’ve found that have become phrases people use in day-to-day talk:

“Otla fola: You will be healed.

“Go tla siama: It will be OK. It will finally get right.”

Chilisa, her colleague at UB, maintains a gloomier outlook. Even the antiretrovirals that allow patients to feel better may delude them and their lovers into thinking they’re well enough to have unprotected intercourse. “We will wait and see what happens.”

Dube acknowledges the problems that remain, such as patients who are living longer, but are unemployed. Now the government has to decide whether it can pay for both food and medicine. But she says she’d rather have “a crisis with hope than to have one with no hope at all.”

“I think we are living in an HIV-positive world,” Musa says. “It’s not just a Botswana problem or an African problem. The world has been living with HIV for 25 years and it has brought us to realize that we are interrelated, so the structures that maintain poverty anywhere must also interrogate their contribution to fueling and maintaining the HIV/AIDS epidemic. We have to own up and ask ourselves how can we create a world that is better for all of our citizens. It should begin with all of us.”

For a handful of Penn doctors, it begins with each day’s rounds. “I think we’re making an impact,” Friedman says. “We’re one of many, but we’re doing our part.”

Dr. Jason Kessler remembers another confused and feverish young man who came under his care at PMH. The patient had never been tested for HIV, but he had the telltale signs of chronic infection: thinning hair, oral thrush, and wasting syndrome.

“We saw him the morning after he was admitted and immediately ran into his sister, who was very concerned about him and related to us that, unlike what he appeared like now, the patient was actually a very accomplished young man. He had trained as a lawyer in Europe and was quite successful.”

The doctors would do what they could, Kessler told her, but the prognosis looked poor.

Then a CAT scan found masses in his brain, which explained his cognition and orientation problems. He appeared to have an opportunistic infection called toxoplasmosis, Kessler recalls. With treatment the patient was able to check out of the hospital two weeks later. “I continued to see him in the HIV clinic at the hospital and started him on antiretroviral therapy.

“Within six months he was nearly completely well, back at work and his charismatic old self. I still see him or his sister now and again around town and they never fail to recognize me and greet me with warmth and thanks,” Kessler says. “So I learned to accept the difficult or terrible outcomes, but I realized that every so often, we are going to alter the course of the epidemic in a young person’s life.”

Susan Frith, formerly the associate editor of the Gazette, is a freelance writer who lives in Florida.

Prognosis Botswana By Susan Frith
Photography by Rick Cushman

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(Left) An AIDS patient receives care in the outpatient clinic at Princess Marina Hospital, one of the largest HIV clinics in the world. Once it was the only one in the country, but now 32 such clinics dispense antiretroviral drugs.

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