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Bonds with Botswana: A Global Partnership Grows

This is part of a series that will profile the BIDMC Department of Medicine's exciting and innovative global projects and partnerships. From Botswana to Vietnam, Medicine faculty and residents are collaborating with hospitals, medical schools and non-profit organizations to improve the health of patients, advance biomedical science and train the next generation of leaders in global health.

Dagan Coppock, MD,  and  Tau Koketse, RNLike many BIDMC physicians, Dagan Coppock, MD, wakes up early each morning and commutes 45 minutes to work. When he arrives at the hospital, he greets fellow physicians, nurses and residents and inquires about patients on the floor. But, unlike most BIDMC doctors, Coppock works thousands of miles from Boston in a district hospital in Botswana. Since August 2011, he has worked as an internal medicine attending physician and clinical preceptor at the Scottish Livingstone Hospital (SLH) in the town of Molepolole, an hour from Botswana's capital city of Gaborone. Botswana is a politically stable country in southeastern Africa, where most of the population lives on the outskirts of the great Kalahari Desert. Coppock's full-time position is funded through BIDMC and reflects a major expansion of the BIDMC-Botswana Program, a key part of the hospital's Global Health Program and the Department of Medicine's Internal Medicine Global Health Program. It also reflects a long-standing but still growing partnership between BIDMC and SLH.

A graduate of Yale Medical School and BIDMC's residency program, Coppock has impressive experience in global health, including time in Ghana, South Africa, Cape Verde and India as well as a stint as a Fulbright scholar in Nigeria. A core part of his job at SLH is supporting and training the BIDMC medicine residents who visit for four-to-six week rotations. His goal, he says, is to "help people get the best medical care they can while simultaneously giving the residents the best education they can get in this unique setting. If I have done both, I am happy." By all accounts, he's got every reason to be happy. In addition to the clinical care and quality improvement efforts that the program fosters, the rotation enables BIDMC physicians-in-training the opportunity to explore the possibility of a career in global health - an often uncharted but critical path within medicine. For Tomer Barak, MD, a second-year internal medicine resident, the time he spent at SLH was a formative experience. "I came away from my experience in Botswana with an even stronger conviction that this is what I want to do with my life, that I had truly found my calling."

Scottish Livingstone Hospital's Director Kitenge Kalenga, MD, with Head HIV Clinic Nurse Belinda Mokgwaela, RNSLH is a 350-bed hospital offering inpatient and outpatient medicine and pediatric services, full obstetrics/ gynecology care, surgical services and an emergency department. Last year, ten Medicine residents and two attendings visited the hospital. SLH has also hosted residents and attendings from the Departments of Anesthesia, Obstetrics and Gynecology, and Radiology. Rotating BIDMC residents receive training in a wide range of clinical conditions and round with fellow residents, SLH physicians, nurses and Coppock. In addition, they prepare teaching sessions for and participate in learning sessions from SLH medical staff. Weekly medical teaching conferences are also available at Princess Marina Hospital, the principal teaching site of the University of Pennsylvania, close to the apartment complex where most residents stay during their rotation.

As part of the BIDMC-Botswana Program, residents are expected to partner with hospital staff to identify and implement quality improvement projects that will benefit SLH. According to resident Tomer Barak, opportunities for learning and improvement abound. "Every day spent on the wards and clinic brings fresh ideas for quality improvement projects and numerous opportunities to educate and be educated," he notes. Given BIDMC's emphasis on quality improvement, Barak says, "One thing that our residents and faculty are able to bring to SLH is a fresh set of eyes that have been trained in a culture of medical education and quality improvement and the time and energy to use their insights to SLH's benefit." And SLH staff members are generally happy to partner with visiting residents, he notes: "There really is a thirst for sharing knowledge and finding ways to improve the quality of care in the hospital. And the great thing is that very small interventions can make a huge impact. In this sense the opportunity for visiting residents to make a real difference is something that has little parallel in the US." The hospital's director, Kitenga Kalenga, MD, also sees the partnership as mutually beneficial: "In my perspective, the world is becoming a small place. This program gives us the opportunity to interact with and learn from one another. The residents have benefited from the things they have learned from our unique, though resource-limited setting. However, we have also benefited from…the QI [efforts] of the residents."

While BIDMC has only recently committed resources to having a full-time attending at SLH, the relationship between Harvard, BIDMC and Botswana is longstanding. In 1996, Dr. Max Essex, a researcher and Veterinarian at the Harvard School of Public Health, started working in Botswana to try to understand the extraordinarily high rates of HIV there (for a Resident Tomer Barak, MDtime, the highest rates in the world). That same year, the Botswana-Harvard AIDS Institute Partnership (BHP) was formed as a collaborative research and training initiative and has grown into a fully-operational research laboratory and training center in Gaborone, with ongoing research and training initiatives throughout Botswana. BHP has conducted many seminal studies on topics such as mother-to-child transmission of HIV, design of an HIV-1C vaccine and HIV drug resistance.

The government in Botswana has received widespread recognition for a progressive and laudable response to the HIV epidemic. Botswana was, in fact, the first African nation to introduce a national program to prevent mother to child transmission of HIV. But despite the domestic and international resources that have been and continue to be dedicated to combating HIV/AIDS in the country, BIDMC residents are often struck by the heavy human toll that the virus and related conditions continue to take there. Barak reflects, "It really is a degree of suffering that we are rarely exposed to in the US, patients who are so emaciated and weak, whose bodies have been ravished by illness to such a degree that every movement, every breath speak anguish and struggle."

While residents may often find the experience challenging, Coppock says he's been impressed with their ability to "jump right in to a medical system which is very different than what they've experienced in the States." Indeed, "What has made our residents so wonderful," he says, "is that they have adapted their clinical skills and knowledge rapidly. Within a day or two they are already a functioning member of the team, seamlessly collaborating with the medical officers and nurses. They face a lot of challenges, but are very quick to turn any frustration they have into proactive and thoughtful medical care." The HIV Clinic's head nurse, Belinda Mokgwaela, RN, agrees: "They are good at taking time with our patients in order to help them both physically and psychologically." While they do contribute important clinical and QI services at SLH, BIDMC residents who've spent time at SLH seem to agree that they've gotten more out of the experience than they could ever offer.

Read more about BIDMC's Bonds with Botswana.