Thursday, June 13, 2013

The Legal Battles within Healthcare in Botswana

I just finished my second full week of clinicals today and I wanted to share a really interesting story. This week I was at Tlokweng Main Clinic which is a much larger clinic than Old Naledi where I was last week. Initially I didn't think I liked this clinic as much because it was darker and more crowded and the doctors didn't really seemed to want to engage with us. However, I soon learned that at Tlokweng Clinic it is the Registered Nurses that are the most informed and knowledgeable about the most prevalent health problems currently in Botswana.

I was finally able to conduct a few interviews with a community health educator and a registered nurse, but in order to save from material for my actual research, all I will say now is that the nurses and health educators are very aware of the fact that it is first and foremost up to the Motswana population to help themselves stay healthy and prevent the spread of disease from others. There is a visible gap between how passionate the nurses and educators are about teaching the Mostwana people, especially young adults and teenagers--they are the most at risk for pregnancy and high rates of HIV--and how willing the population is to take that advise seriously. We are going to be spending a week at a local village in two weeks so I hope that I will be able to actually see of this community education at work and compare it to the educational methods being used for HIV and teen pregnancy prevention in the clinics.

But now, what I was most excited to talk about was my day today with a Registered Nurse who works as the HIV counselor. Her principal role is to provide guidance and education to newly HIV-infected patients who are just about to start their baseline round of ARVs. Initially I actually thought counseling was just for this purpose, but I learned today that at Tlokweng, the majority of patients that come in for counseling are those that are "defaulting." This means that patients are either failing to take their drugs on a daily schedule and at the same time every day and/or they are not coming in to refill their prescriptions and have their CD4 counts checked every two months or so too ensure that their body is responding well to the anti-retroviral therapy drugs.

The first patient that I saw today came in with his mother (he was around 32 years old) and a long conversation in Setswana ensued for about 20 minutes and it was apparent that the man was becoming very ashamed as his mother was talking to the nurse for he was looking at the floor for the majority of the conversation. The nurse eventually paraphrased the conversation and informed me that the mother was here with her son because he had previously defaulted three times which means that he has failed to take the drugs properly and has been abusing alcohol for years which in turn was creating adverse side affects to the ARV drugs. Thus, the nurse explained that because the man cannot be trusted to keep up with his medication regimen and come in routinely to have his vitals and CD4 count checked, his mother must now be in charge of not only watching him take his ARV drug every day, but she must also accompany him to his clinic visits. Furthermore, if the man refuses to go to his monthly or bimonthly visit, his mother must come to the clinic herself and inform the nurse of his actions.

This entire conversation really opened my eyes in realizing the struggles that entire families often face when one family member becomes HIV-positive, and often it has to do with not wanting to tell significant others, partners, or even family members about their HIV-status, therefore they do not want to be caught taking the drugs, so they stop adhering to the treatment program all together.

The second patient I saw was a 29 year old man who came in with his uncle (though initially I thought perhaps it was his brother or his partner). I learned from the nurse that the young man did not have any parents and that both he and his uncle were unemployed and have no money, and the 29 year old has been HIV-positive since 2009. The young man has never received any ARV treatment however, because he has never owned a National Identity Card (sort of our version of our drivers license), thus he does not have proof that he is a citizen in that way or in any other form because his parents are no longer alive. So the reason that the two men came in for counseling today was to have the nurse write a statement to the Chief of their village asking for him to sign off on the young man's uncle becoming his legal guardian so that he can obtain a National Identity Card and start ARV treatment. I was informed that because the ARV treatment program is regulated and fully funded by the government, anyone who is not a Botswana citizen is unable to participate, thus because this young man couldn't prove that he was in fact a Motswana, he has never been able to receive any treatment. And so the nurse complied and wrote a letter to the Chief of their home village and also talked to a social worker at the clinic to arrange for transportation to the village to ensure that the two men would be able to successfully get to their village and deliver the letter and ultimately have the young man come back to the clinic and start the baseline treatment for HIV.

The most interesting part about this who situation was the nurse's story about how in the past their clinic has discretely treated patients who haven't had identity cards, but often it turned out that the patients were not Motswana, but rather from a neighboring country. Thus the clinic became very conscious of the legal implications of their actions, and now have a system in place where the computer continuously alerts the nurses and doctors if there is a patient participating in the ARV program that does not have a National Identity Card. The nurse was incredibly knowledgeable about the need for proper and timely legal representation of their clinic in order to ensure that blame does not fall back on them if a patient doesn't comply with medication or treatment guidelines and decides to sue the clinic for misconduct.

This part of medicine is so fascinating to me, and I am so excited that I'm finally getting to learn about some of the legal battles first hand. I'm really starting to get a sense of how government regulated health programs often don't consider the legal implications of their programs in terms of the clinics having to figure out the kind of legal assurance they feel most comfortable with and makes the most sense for their patient population.

In other news, I am off to Serowe (in Southern Botswana) to visit the Khama Rhino Sanctuary! We will be rhino tracking in the early hours of the morning and going on a night safari as well, pictures to follow in the next post!

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