Things have been going on faster than I can write about them – my handwritten notes are starting to pile up! – so I wanted to do a quick catch-up. I really feel like time is flying by now, mostly because of end-of-Watson pressure, but also because there’s more going on in Botswana than I thought.
I’ve already had a few project meetings, and there are some very cool mHealth (mobile health) endeavors here. Many of these projects come from the University of Botswana, which has a campus in Gaborone and a partnership with UPenn back in the US. From the Botswana-UPenn Partnership (BUP), I learned about TB-PEPFAR, their project to improve TB screening and testing in Botswana. One aim of the project is to provide community health workers (CHWs) with phones to collect data on TB patients. The phones use a mobile application called RedCap, which provides secure data capture for researchers and also allows CHWs to fill out digital forms rather than paper ones.
PEPFAR, or the US President’s Emergency Plan for Aids Relief, focuses on the diagnosis and treatment of TB because the infectious disease is so common in HIV patients – it was the cause of one-third of AIDS-related deaths in 2015 (source). This is particularly relevant here in Botswana, where the biggest public health crisis is HIV/AIDS (it is the leading cause of death, accounting for 32% of all deaths according to the CDC).
A week ago I traveled with a doctor of the TB-PEPFAR team to Lobatse, a small town an hour south of Gaborone. He was there to oversee a small conference for nurses and doctors from clinics in Lobatse and surrounding areas. As it turned out, the attending health workers were not users of the RedCap app – the conference was really a training session to update the health workers on the best methods for TB screening. Even though the training day wasn’t about entering data with RedCap, I was still curious to see if technology would come up in another way.
Also, I learned a lot about TB. I became interested in medtech via the technology, not the medicine, so I still have a lot to learn about basic medical topics. During my stay in Lobatse, I learned about the importance of ‘sputum’ for TB diagnosis (I had never heard that word before, but sputum is the name for the mucus-y fluid that you might cough up when you’re sick, and testing this sputum is essential to TB testing). I learned that alcohol, overcrowding, and HIV/AIDS all contribute to TB. I also learned that while sputum induction (SI) is one way to diagnose TB patients, there is another method, gastric aspiration (GA).
The day’s training included “how to”s for both methods, SI and GA. GA was the more complicated and time-consuming method presented, requiring more equipment than SI – including a nebulizer. The presenter of this section had a nebulizer on the table and began demonstrating how to use it. One of the conference organizers, sitting in the back, called out: “Is this the nebulizer you all have in your facilities?” Everyone shook their heads or said “no.” The presenter went on with the nebulizer demonstration, though it seemed obvious to me that everyone would prefer the SI method. He later told me that since there were so many stakeholders in this TB-PEPFAR project (including both the US and Botswana governments), it was difficult for them to change or skip slides from a pre-approved presentation.
One of the topics of conversation throughout the day was, of course, how to diagnose patients who have both HIV/AIDS and TB. The same organizer who asked about the nebulizer above told me that TB in HIV/AIDS patients manifests quite differently than TB alone. She said that it frustrates her when medical students from American universities come into Botswana and try to diagnose TB just based on the theory they’ve learned (without recognizing that in some cases, she said, HIV/AIDS patients with TB will test negative for TB). She said that it’s a feeling you have to develop about HIV/AIDS patients – whether they have TB or not – and treat for it even if there’s no conclusive evidence. I thought that was a fair frustration and a good example of why it’s important to know the medical particularities of a place before you treat, diagnose, or develop medical devices for various conditions.
Finally, there was a moment where the nurses and doctors discussed what might contribute to Botswana’s high TB rates – the possible social, cultural, biological, and policy factors – and I wonder if these factors also affect medical device acceptance here. The interesting answers included: high HIV prevalence (of course); migration; non-adherence to policy; not enough people in healthcare management due to the small population; and the use of traditional medications and going to church instead of seeking immediate treatment at a hospital (I have noticed that religion is quite important here – more on that later).
At the beginning of this year, I would start with examples of individual devices and only focus on cultural factors once I could generalize trends across those conversations. Now I find myself approaching both at once, looking for those cultural trends right away so that I can keep them in mind as I encounter various medical technologies. I suppose it’s a good thing because it means that I’ve gotten faster at identifying the important factors for medical technology adoption – the “big picture” stuff – without needing so many small steps to get there. That said, I’m still looking forward to learning more about specific medical device and eHealth projects here!