Back in the months of September and October in Botswana, all the nurses were on something called a “go slow” very similar to a labor strike in the States. It means that they were refusing to do anything more than what duties are listed in their job descriptions. This was apparently a country wide strike, and the reasons they were given for it were that nurses were not compensated well enough, and that they were doing jobs that should be done by doctors or pharmacy technicians.
There is a shortage of health professionals as a whole in Botswana, many nurses and nearly all the doctors come from neighboring countries (which also contributes to the communication barrier and mistrust between villagers and medical professionals). I’ve been told there is a medical school being built in Gabs which will hopefully help with this shortage. Right now the government supports students who want to pursue a medical degree in other countries that have medical schools, but I’m uncertain if there is a provision for them to return to their home country to practice medicine.
One of the first problems with a strike in a developing country like Botswana lies in the fact that all nurses are employed by the government, and thus there is little opportunity for any productive negotiation. The nurses were demanding something like a 60% increase in their salaries, and it makes for a sticky situation when the government cannot intervene on behalf of the people who are experiencing interrupted services. The effects of such a strike might be felt a bit less in communities that are large enough to have a hospital, where doctors could step in and help with the overflow of patients not being completely treated by nurses. But in a community like Seronga it was a nightmare.
The nurses in Seronga, (who were incidentally running short staffed with only 2 or 3 nurses –we are considered fully staffed when we have five- for the duration of the go slow, which is thankfully over now) weren’t prescribing any pills other than those deemed absolutely necessary, like malaria drugs. They would triage serious wounds and injuries, but referred a huge number of people to the doctors at the hospital in Gumare, a 300 k one way trip around the delta with very few boats and ambulances going through rather than around… (and now might be the time to mention the lack of public transport for the first 100 or so kilometers on this side on the dirt road, a pretty unpleasant journey if you are healthy, much less injured or sick in the back of an open truck with dust and dirt or worse yet rain flying at you). The clinic’s biweekly boat/ambulance trips to deliver the blood to the hospital in Gumare for analysis were extremely full of patients trying to get to the doctor to be seen for conditions the nurses were refusing to treat. The go slow also had a domino effect of causing all the health education workers and clinic cleaning staff to reevaluate their duties and there were many smaller yet important cleaning and educational functions that were not being performed at the same time. It was a very difficult time for the morale of everyone.
HIV testing, which is usually done by the lay counselor, with back-up from the nurses, was not being done when Pulane was out (and he was out quite a lot, they get an amazing amount of off days in Botswana). There were a few instances where I was near tears of frustration and calling in every favor, and using every begging, pleading and threatening method I could muster with the nurses to get them to test. Admittedly, they were between a rock and a hard place (in Batswana culture I have found that there is a great emphasis on obedience and following directions very specifically, with little thought towards if the command given makes sense for the situation at hand, or if there might be a more effective or efficient way of getting things done.) but could usually be convinced if for no other reason than to shut me up. I found that the nurses at the health posts and mobile stops had run out of testing kits a while back and although they weren’t refusing to test, they were refusing to order more tests, as this was not supposed to be their job. The DBS (dried blood spot) tests that were supposed to be done on babies were occasionally getting done, but not submitted to be analyzed.
Don’t get me wrong, I understand where the nurses are coming from, maybe not on the pay dispute (in relation to other Southern African countries nurses in Botswana are very well compensated, in fact we have many nurses from Zambia and Zimbabwe who have come here to earn money to send home to their families, and I know they are making a hell of a lot more than me right now) but certainly on the job duties. Although nurses trained in Botswana are given a short course on pharmacology, (having spoken with them about the issue they emphatically state that they do not feel qualified to dispense drugs in the manner they are, especially not when the drug interactions with local methods of traditional healing methods are taken into consideration) there should definitely be a pharmacy tech as well as a doctor on site. There is, in fact a doctor and pharmacy tech living in Shakawe who are specifically assigned to Seronga. They make the trip down the dirt road from Shakawe to Seronga two Mondays per month. The doctor and phamracy tech get patients started on ARV’s when the patient’s CD4 count drops below 250 (ie they start to get real sick). The doctor will monitor the patients at appointments on these two Mondays per month for three months. After that the patients are expected to follow up and get their medications from Shakawe. Right. The inability to make their way to Shakawe for whatever reason has caused many people to default on their ARV’s, or to develop immunity to the effectiveness of their ARV’s, after which they should probably be referred to Gabs for a third or fourth line drug. This doesn’t happen, as if they can’t get to Shakawe 100 k’s away how on Earth will they make a three day’s journey to Gabs? It’s not difficult to understand why villagers resort to the local roots and pseudo-medicines of the traditional healers. With respect to traditional healers, I understand and admire their attempts to heal and cure the people through age old methods, and am willing to bet that for common ailments they have the ability to provide a great deal of comfort and help. However with AIDS they really don’t stand a chance. I’ve seen many people who consult traditional healers get very ill very quickly, and many have died.
In Seronga we have a big, beautiful, red brick ARV building that stands locked, empty and unused. Currently we don’t have adequate housing on the clinic compound for the nurses who work at the clinic (It is part of government employees’ contracts that they are provided government housing in the village they are sent to. This is normally where Peace Corps volunteers are housed as well) and so we don’t have housing for a doctor, either. It’s shocking to me that the government would have gone through the trouble of building such a beautiful building without plans to provide the housing for the doctor and pharmacy tech as well, but that is apparently what has happened. I suspect that like most services promised to Seronga, the government rushed to put up the building to placate the people, to quiet their demands and complaints, without the necessary follow through to make it functional. While I understand how difficult and expensive it is to get building materials and laborers this side, that’s not really a good enough excuse for me.
Although there are open houses on the police compound I’ve been told the doctor refuses to come to live in an area where he cannot be supplied with 24 hours a day electricity. In some ways I can’t blame him; this is a less than desirable life for someone who went to medical school to improve themselves and their career and lifestyle opportunities. There was a Spanish woman with the British Skillshare program who had been working as a volunteer at the Okavango Poler’s Trust to try to improve their marketing. She lasted about 6 weeks. Many of the professional employees (teachers, police, nurses, ect) have expressed dismay and depression at being placed in Seronga, and have recently requested both hazard pay and a rural placement bonus from the government. It’s the bush and it’s not easy and it’s frustrating and I get that. I certainly spend enough time wanting to get out of here, at least for a while. I understand that a life like this isn’t for everyone, but I am still nevertheless distraught at the lack of services being provided to the villagers in Seronga.
Although the strike is over, the level of health care provided in Seronga is still discouragingly under par, despite the increased efforts of the nursing staff at the clinic. As someone who has been sent here to build the capacity of aforementioned entity, it is frustrating to feel that you don’t have the complete support and commitment of the government that has requested you be here. It's frustrating to stand by and witness these problems that are amongst the many I have nothing feasible I can do about them. It is during these times of tear inducing frustration that I am reminded again that change takes time. I search for the things this village has going for it, the people who do care, the ones who are doing things, and dream of the place Seronga can be. I still have hope.
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