Just this month, in fact, a delegation from the sub-Saharan African nation — including Loeto Mazhani, deputy secretary of Botswana's Ministry of Health; Esther Moaro, the chief nursing officer in the Ministry of Health; and Botswanan ophthalmologist Oathokwa Nkomazana — came to town to discuss developments in an AIDS treatment program that's had a local connection for years now.
Spearheading the endeavor on the Philadelphia side is Harvey Friedman, chief of infectious diseases at the University of Pennsylvania. An AIDS expert, Friedman had no experience with the epidemic in Africa; that is, until the turn of the 21st century, when a philanthropic team including the Bill and Melinda Gates Foundation, the government of Botswana and the charitable arm of Merck tapped the 62-year-old physician for medical duty.
These days, the Merion resident leads a comprehensive AIDS program there, complete with seven full-time physicians who live and work in the African nation year-round, as well as about 50 medical students, residents and interns who practice medicine there six weeks a year.
"If we're going to make an impact, you can't just look at the United States," said Friedman, sitting in his West Philadelphia office. "We need to try to have a foothold where the epidemic is."
'It's a Huge Problem'
The program, which began in 2001, focuses on two main components: seeing patients, and teaching in-country medical personnel to do the same.
Friedman said that the former entails providing AIDS care — prescribing anti-retroviral drugs to manage symptoms, and treating opportunistic infections, like tuberculosis, that tend to crop up — to patients at two public hospitals in the country, as well as at nine smaller district facilities.
At the same time, the program's medical staff helps train regional doctors, the quality of whom Friedman admittedly described as "mixed."
"If no one knows how to do a culture, you can't buy a machine that will do you any good," explained Friedman. "They need the personnel," he said, while the university's job is to cultivate some "A-plus physicians."
Okay, but why focus these efforts on Botswana?
Friedman explained that the need for AIDS treatment in the sub-Saharan nation is great — at 32 percent, it has one of the highest prevalence rates in the world — yet because Botswana is so sparsely populated (about 1.8 million people live there, compared to South Africa, which has roughly 47 million), it still has fewer AIDS cases than some of its African neighbors.
Botswana is also home to a stable, democratic government that fosters a "very pro-HIV" environment, according to the doctor.
"In other parts of Africa, especially South Africa, the governments at that point were saying, 'It's not a problem, there is no HIV in our country,' " reported Friedman. "In Botswana, the president said, 'It's a huge problem, and if we don't address it, we won't have a country in 10, 15 years.' "
These conditions have attracted philanthropic organizations, who in turn have been pumping money into the country's AIDS infrastructure, said Friedman.
The Penn program was borne out of one of these initiatives.
In 2004, President Bush's Emergency Plan for AIDS Relief, which pledged $15 billion to 14 nations in the fight against AIDS, added just under $1 million to the pot. Today, the program also receives funds from the National Institutes for Health, the Haas Foundation and a number of private donors, not to mention about $500,000 from Penn itself.
Though Friedman described the Botswanan medical system as "good by African standards," he said that care there is "certainly well below the standards we would practice here."
Among other problems, he noted that Botswanan hospitals are plagued by a huge volume of patients, substandard equipment and constant supply shortages.
"Every day, there's something else that runs out — an antibiotic or another drug or an IV solution," he said.
The challenges are so vast, in fact, that Friedman recognizes that his team cannot go it alone. That's why he's working to galvanize other Penn departments.
With the Botswanan delegation in tow, Friedman's schedule last week included discussions with various medical specialists (emergency medicine, dermatology, etc.), as well as with leaders in the fields of nursing, veterinary medicine and social policy.
In fact, the Wharton School of Business, Friedman noted, currently runs an entrepreneur project in the country.
"Our goal is to get as much of the university involved as possible," stressed Friedman. "HIV — more than any disease I can think of — needs a multipronged approach."
Already, Friedman said that there have been signs of progress: Since the program began six years ago, the percentage of those infected in Botswana has dropped 6 percent.
Another positive sign: Next year, the country will open its first medical school.
"I look at Botswana as sort of the test-tube case," said Friedman. "I feel that if we can't make a dent there, that would be a very negative statement.
"But we are making a dent," he continued, "not just Penn, but we — as the international community."