A Penn-Botswana tie born of AIDS crisis

When Stephen Gluckman was first asked to help Botswana stem its AIDS epidemic in 2001, the University of Pennsylvania infectious-disease specialist expected to be there only three months.

But then he set foot in Princess Marina Hospital in Gaborone and was touched by what he saw: a crowded facility with patients on mattresses in the halls, people sicker than any he had seen in Philadelphia, and many babies infected with HIV passed on by their mothers.

They were the face of Botswana, a country in the center of Southern Africa with one of the world's highest HIV/AIDS rates. Four out of five patients at Princess Marina were HIV positive.

Over the next seven years, Gluckman spent five months a year in Botswana, paving the way for many more Penn doctors and medical students to join in what has become Penn's largest global partnership, now involving other departments besides medicine.

Joining international AIDS-fighting groups and the government of Botswana, Penn played a role in the success of the HIV- and AIDS-reduction program: Today, only 6 percent of mothers pass on the virus to their infants, down from 40 percent.

"Penn's really been heavily involved. They've been crucial," said James C. Shepherd, care and treatment team leader for the U.S. Centers for Disease Control and Prevention, Botswana. "Amongst others, they have supported extremely effectively one of the best treatment programs in the world."

And now, Penn is helping Botswana launch its first medical school and will occupy a floor in a new building.

"It's amazing. I feel lucky to be a part of it," said Gluckman, 63. "I have spent a fair amount of time overseas, but nothing has come close to feeling this big of an impact."

About 250 Penn doctors, medical school students, undergrads, and staff rotate in and out of Botswana each year, providing care, teaching, researching, and serving in undergrad internships.

The program has grown to include staff and students from other Penn departments, such as the Wharton School, the veterinary school, and Annenberg School for Communication.

Veterinary students tranquilize antelope on the edge of the Kalahari Desert to check their health or relocate them. Education students teach at orphanages. A law student writes draft judgments for a high court justice.

The university also employs a staff of nearly 60 doctors, nurses, administrators, and assistants there - many of them Batswana. (Batswana describes more than one native; Motswana is singular.)

The Botswana-Penn partnership operates on a $6 million budget - about $800,000 from Penn and the rest from U.S. government and private grants, including the U.S. emergency AIDS-relief program.

While the partnership accounts for only a small fraction of Penn's $5 billion budget, the initiative has had far-reaching effects in Botswana and on Penn's West Philadelphia campus, officials say.

For Penn, the global experience has created a ripe training ground for students to learn to treat seriously ill patients without advanced care or advanced technology.

For Botswana, Penn staff provide a rich array of coaching and expertise in specialty areas, while advancing medical education there.

"It's been so productive on both sides," said Penn president Amy Gutmann, who visited Botswana in 2007 and met with its president. "Our students and faculty find it life-transforming."

Loeto Mazhani, a medical school physician and formerly a lead physician in the country's Ministry of Health, hopes the partnership grows: "It's a two-way benefit."

In early summer of 2001, Harvey Friedman - chief of infectious disease at Penn - received a call from the Merck Foundation, the charitable arm of the Whitehouse Station, N.J.-based pharmaceutical company, asking for help to train doctors in how to use antiretroviral drugs, which slow the virus.

At the time, the country of nearly two million, which is smaller than Texas, was in crisis: Thirty-eight percent of people 15 to 49 were infected.

With its burgeoning diamond mining, Botswana could afford to mount a war on AIDS, but it needed help. Merck with its foundation and the Bill and Melinda Gates Foundation each committed $56.5 million to establish the African Comprehensive HIV/AIDS Partnerships.

Merck also agreed to donate antiretroviral drugs.

Friedman turned to his colleague Gluckman, a Brooklyn native with a reputation as a globe-trotting doctor. Gluckman, who lives in Mount Airy with his wife, a physical therapist, had worked over the last 30 years in Tanzania, Kenya, Uganda, Liberia, Afghanistan, India, China, and Haiti.

He had started the infectious-disease division at Pennsylvania Hospital and was eager to go abroad again.

Botswana was challenging.

While it had become a wealthier nation, it was behind technologically. The country lacked enough labs for testing, clinics for monitoring, and training to conduct treatment as advanced as in the United States.

Even today, Botswana has no MRI machine and only one CT scanner. Doctors often must rely on physical exams to diagnose. Specialists are rare.

It's vital that AIDS medication be taken on a strict schedule. A national program would have to emphasize timely treatment even though many people don't wear watches and many homes lack refrigerators to preserve the drugs.

"So unless there was a lot of attention paid to this, ultimately the program would fail," Gluckman explained.

Early on, he found himself frustrated, stuck in meetings. Then, on his own, he began visiting the local hospital and working with doctors eager "for any drop of medical teaching" he could give.

"My third month there, I had my own team," he said.

By the end of the stint, he realized that he - and Penn with its vast knowledge and resources - could do a lot for Botswana and for its own medical trainees.

"It just struck me. Hey, maybe we should make this into a formal thing," he recalled.

Penn fronted start-up money and helped the doctors find other funding - enough to pay for flights and rentals for visiting students.

Princess Marina Hospital tends to operate at 150 percent capacity. Family members fill the wards, feeding and caring for patients because there is a shortage of staff.

Drugs, IV fluid, and other supplies are often out of stock; soap and towel dispensers are empty. Gluckman said the shortages occur because someone forgets to order, not for lack of money.

Everything seemed to move slowly, a pace that at times left Gluckman frustrated.

"It would be nice if there was more corruption, so you could actually pay somebody to get something done," Gluckman quipped.

Penn nursing students who arrived this month were stunned that the country held up medical supplies they brought. Eventually, 75 percent got in.

"We had to send back all medications, vitamins, antacids, iron pills, condoms, and first-aid creams," student Don L. Payette Jr., 46, said in an e-mail. "The Ministry of Health would not allow any products in which they did not have complete confidence. This included brands like Tylenol!"

Payette complimented the Batswana on their caring for each other and said he and the other students are learning a lot from hundreds of patients, including those with advanced AIDS.

"One group of students performed breast exams on women who had never had them before - and found a few lumps that need to be immediately examined. In the desert, we performed physical exams on children who had most likely never - ever - had any health care at all," he said.

Penn doctors say the experiences have been equally rewarding for them.

Robin Canada, 35, a Penn internal-medicine doctor who spent six weeks there as a medical resident in 2004, said the experience affirmed her passion for caring for underserved populations whether in Philadelphia or abroad.

"It's just the idea of trying to provide equity," she said.

Keeping Penn medical residents, students, and doctors safe is a major concern with the prevalence of HIV and tuberculosis. Accidental needle sticks luckily haven't resulted in infection, Gluckman said.

Other dangers also exist: Richard K. Root, Penn's founding chief of the division of infectious diseases, was killed in 2006 by a crocodile while on a guided tour. He was teaching in the program.

The Botswana experience has become a major draw for Penn's medical school; more than 80 students applied for 36 Botswana rotations last year.

Gluckman understands its popularity: "This has nothing to do with being Mother Teresa. I get way more out of it than I give."

Patients are especially appreciative, and because of national health care, doctors don't have to fight with insurance companies, he said.

"I don't have to get approval if I want a chest X-ray on somebody from some clerk," he said. "All the crap that gets between me and taking care of patients is gone."

When Amy Gutmann became Penn president in 2004, she quickly identified global partnerships as a priority.

Penn has been developing and expanding ties with China, India, Guatemala, and Peru, in addition to 1,000 one-on-one partnerships between faculty worldwide.

Gutmann, however, emphasized that Penn continues to provide strong support in its neighborhood - an effort launched by previous Penn leader Judith Rodin.

"It's not a trade-off in my mind," Gutmann said. "We're in such a strong position that we can do both."

Gutmann created a formal partnership with Botswana and expanded it. Penn specialists put on mini seminars for doctors there. The first dental student arrived this summer and did 30 extractions in a day. Undergraduates are interning in areas outside medicine. One student this summer is looking at the influence of mining natural gas on the environment.

For the first time, a Motswana - Mosepele Mosepele - is a medical student at Penn.

Earlier this month, Penn doctors assisted the country in opening its medical school to a class of 36 students, who will become Botswana's first homegrown doctors. In the past, Batswana left for medical training and few returned home to work, leading to a "brain drain," Gluckman said.

Penn doctors helped to design the curriculum and interviewed candidates for faculty positions.

As part of a new $11 million five-year federal grant, Penn will help train students. Doctors, including Gluckman and Friedman - who heads the Botswana partnership - are on the medical school staff.

"Our role will not be so much in the classroom, but more at the bedside" when students begin rotations, said Friedman, in a telephone interview from Botswana.

Penn is contributing $2.5 million for a new medical building and will occupy a floor for medical research.

The country's effort to stem AIDS - including a massive public-awareness campaign and treatment program - has yielded results.

The HIV rate has declined slightly, but more important, people are living longer, officials said. Pediatric cases are becoming rarer.

And coffin makers now can keep up with the demand, Friedman noted.

Penn officials hope in the next decade that the need for their medical expertise will fade away and the partnership will grow more into a student and research exchange.

Gluckman remains tied to the Botswana program, but works full time at his Philadelphia practice. While many of his patients have been supportive - one bought a house in Botswana to rent to Penn students at a modest price - others bemoaned his long absences.

Still, he's glad to have done the job.

"Most people," he said, "never get to have that much influence on health care in another country."