The Africa Connection

In 2001, Botswana’s President Festus Mogae told the UN General Assembly, “We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the highest magnitude.” At this time, Botswana had the highest HIV rate in the world – 22 percent of the population. Its entire health system was in need of urgent reform.

The UN responded by setting sustainable development goals for Botswana. The health and wellbeing goals included ending the epidemics of AIDS, tuberculosis, and malaria, and reducing maternal and neonatal mortality rates. And countries across the world stepped up to help Botswana achieve those goals. Both the Bill & Melinda Gates Foundation and Merck & Co injected money into tackling the problems, and four American university medical centers were recruited to share their expertise with partners in Botswana. Their mission? To build capacity and excellence in clinical care, education, and research.

In 2015, Kumarasen Cooper and members of the University of Pennsylvania (UPenn) Global Health Program conceived the Department of Anatomic Pathology’s partnership with the University of Botswana. Here, Cooper shares the inside story.

How would you describe the state of pathology in sub Saharan Africa?

There are some countries that have only one, two, or three pathologists – some countries have no pathologists at all. In Africa as a whole, there is often less than one pathologist per million population. 

Some problems we have encountered are difficulty in ordering stains for tissue samples, and limited access to maintenance for faulty instruments. When I’m in Botswana, occasionally all the lights in the lab will go off – or the water supply will fail.

What exactly is the Botswana–UPenn partnership?

Twice a year, in April and October, I visit the University of Botswana for an entire month to teach surgical pathology to their anatomical pathology residents. I run classes in specimen grossing and histology, laboratory management, quality assurance, and autopsies. We aim to help them improve in all aspects of quality assurance from turnaround times to sample preparation. We also help them build their knowledge for completion of their board exams, so we can grow the number of qualified pathologists in the country. Sometimes we provide consultation for difficult cases.

As part of the program, we offer a Global Health rotation to our UPenn pathology residents. A group of them accompany me on my visits to experience pathology in a developing country and increase their knowledge of diseases and tropical infections that they are unlikely to experience in North America.

We also offered two Batswana residents a reciprocity rotation in UPenn. I was able to raise funds from my own department, as well as the Global Health Program, and they were able to fund the visas, accommodation, daily subsistence, and so on. I personally took care of picking them up at the airport, taking them to accommodation, and their general wellbeing. My residents, who had been to Botswana, helped our guests with their rotation within the department – sitting in at signouts, lecture programs – anything they could do to help. They all really bonded and had a great time.

What does the University of Botswana gain from the partnership?
 

We give them insights into newer technologies that they may not have seen. In terms of our basic investigative assays, we can demonstrate immunohistochemistry, in situ hybridization, as well as molecular sequencing. And they enjoy it! I take boxes of slides with me as case studies to teach on the multiheaded microscope with monitors. Four University of Botswana residents have completed training and board examinations since establishing the partnership, and they are now employed as attending pathologists in Gaborone.

And what do the UPenn residents gain from the experience?
 

They gain a wide breadth of experience from seeing pathology practiced in a different setting, and from social interactions with the local pathology residents, which they enjoy enormously. It broadens their outlook, and some of them talk about going on to global health as part of their careers.

Participating anatomical pathology residents have told me that this partnership was an important factor in choosing to join the UPenn Pathology Residency. This program can continue to help recruit potential residents who value global medicine as part of their training.

And what do you gain from this type of outreach?
 

It’s entirely a labor of love for me because I was born in Africa. Having now spent 25 years in the US, it’s an opportunity for me to “give back” – and also to spend two months of my year back in Africa, which I enjoy very much. It is also a pleasure to interact with the residents, faculty, attendings, and consultants.

I also enjoy the connections and friendships that have built over the repeated visits to Botswana, and the interesting people I get to meet from different walks of life. It’s important to continue the relationships between the visits as well. You have to be available to help with difficult cases. They send me consults by email, or text, even WhatsApp, and I always try to help them.

How has the program grown since its inception?
 

In 2022, I started to think about sharing this program with South Africa, which is where I was trained. I approached two departments that I had connections with – Durban, where I trained, and Wits University in Johannesburg, where I was Chair for six years in the 1990s. So now, our visits include a week in each of the three partner departments, delivering education and sharing invaluable experiences.

How do you spread the word about your fantastic work?
 

I talk to other institutions about the program, I’ve done a few grand rounds, and I’ll be doing a webinar with The Pathologist soon. But there are other Universities doing great things too. Harvard, Baylor, and Rutgers all have programs in Gaborone, Botswana.

Life expectancy in Botswana is on the rise, compared with 2001, and HIV therapies are widely available now. But the HIV infection rate is still high. There is still much work to be done to protect the health of the Batswana.