February 3, 2009

Rutgers Prof Talks About State Of Patient Health in Botswana

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Yesterday, about 30 graduate students, faculty and post docs gathered in Rockefeller Hall to hear Rutgers’ Prof. Julia Livingston speak about her experiences with oncology in Botswana’s hospitals. Livingston spoke as part of Cornell’s Department of Science and Technology Studies’ (STS) colloquium series.
“The colloquium series is an opportunity for graduate students, post docs and faculty to forge ties with related disciplines across campus [through various speakers],” said Prof. Sara Pritchard, science and technology studies, and colloquium series coordinator.
Livingston is an associate professor of history at Rutgers University in New Jersey. She received her Ph.D. from Emory University, her master’s degree in public health from Boston University and published her first book in 2005, Debility and the Moral Imagination in Botswana. Livingston is currently working on a project to improvise medicine in Botswana.
Livingston explained that despite the fact that Botswana has a stable democracy, a functioning economy and a universal healthcare plan in addition to being at peace without a deficit, it still remains “remarkably poor.” A third of the population lives below the low poverty line.
Within the past decade, Botswana has also been at the epicenter of the African HIV epidemic.
“For most of the past decade, [Botswana’s] national population had a 33 percent HIV prevalence rate for adults ages 15 to 39,” Livingston said.
Even for those in Botswana who avoided the HIV virus, a major cancer epidemic has begun. Botswana has a higher rate of cancer than the United States or Canada.
“Across Africa, a cancer epidemic is approaching rapidly,” Livingston said.
Livingston expressed her desire to “look to Botswana and see what questions this emerging epidemic raises.”
First, she addressed the problem of inadequate facilities.
She lamented the fact that Princess Marina Hospital, Botswana’s central referral hospital, cannot meet the demand of its patients.
“There are hospital beds on the floor, women packed on mattresses in storage closets and the waiting lines for clinics look like Penn Station,” Livingston said.
The limited amount of space in hospitals has tremendous implications for where and how people die. Ambulatory patients (those capable of walking) on chemotherapy are given push injections and sent home on buses or to other hospitals because there is no room for them to sit with drips or even to get the full extent of their chemotherapy treatment.
The shortage of beds also means that dying patients are sent home. This leads to tension between families, doctors and nurses as they rarely agree who should be sent home to die. In Botswana, there is “a particular pragmatics and ethos that partially diverges from the choice model of healthcare that operates in the West,” Livingston said. “Decision making is always socially distributed.”
Beds are saved for those who need a doctor’s care and who’s lives can be saved.
In Botswana, “every effort is made to [send] the dying back to their homes or to doctor’s care and whose lives can be saved.
In Botswana, “every effort is made to [send] the dying back to their homes or to peripheral hospitals in the system,” Livingston said.
A new emphasis on patients’ autonomy arose in the 1970s. However, in Botswana, Dr. P., the PMH’s head oncologist, combats this emphasis on autonomy by sometimes instructing the relatives of patients not to reveal to their ill family members the full extent of their prognosis.
This is especially difficult as extended family members in Botswana are generally not as close as they once were. Even though autonomy has become increasingly important, it is more difficult to obtain because, as a resident in Botswana recognized, “not all relatives are equally situated [and trustworthy].” Even though the extended family is not as involved as it used to be, the extended family members are still relied on by the doctors in caring for the patients.
The lack of patient autonomy in Botswana is made difficult because the country does not follow the same methods as in many other parts of the world. In most countries, doctors prefer to build up their patients’ tacit knowledge of their condition, but Livingston said, citing oncologist Dr. P. that doctors either rely on family members to talk to the patients about their conditions, or their busy schedules force them to divulge all the information at once rather than slowly building up to it.
With eroding patient autonomy and doctors and family members making patients’ decisions, Livingston is concerned about this type of paternalism in medicine.
“Paternalism lies somewhere at the heart of international health, and it can be very, very dangerous,” Livingston said.
Botswanan culture emphasizes hope, and sometimes this too can lead to doctors withholding prognoses, Livingston explained. For many patients, hope can provide balance and keep them from giving up.
Elena Simakova, a post-doc in the Center for Nanoscale Systems, pointed out how many institutions can actually provide hope. But in Botswana, medical facilities remain too crowded and, as a result, remain victim to unethical practices that impede providing patients with the actual hope and promise that they need.
Furthermore, Livingston explained that her interviews with patients often turned into counseling or translation sessions. Doctors and nurses must communicate complicated and jargon-laden biotechnological truths through analogy. But nursing assistants and doctors sometimes failed to translate these technical details effectively to the patients, leaving it to her to complete the translation.
“This can lead to serious ethical dilemmas,” Livingston said.
While cancer is very iconic and familiar to Americans today in Africa and Botswana, the first time many are introduced to the cancer is when they are told they have it. For now, Livingston concluded, “Biomedicine is still so foreign to them.”