Disclaimer: Thus far I haven’t really focused much on writing about my work experiences because it is difficult for me to process everything I have been through. I hate putting negative thoughts onto paper and I hate to appear as if I am judging others. I also really prefer to focus my energy on more fun and positive experiences. But an important part of my time here is to learn from my experiences so I want to document how I have been feeling and how my perspectives have changed over time. I really don’t think it is fair to make blanket judgments about other cultures but after living here for almost a year, I feel that I have earned the right to share my thoughts, perspective and experiences of adjusting to cultural differences (with the clear caveat that my statement do not apply to everyone in Botswana or every experience I have had).
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They say expatriate workers generally go through predictable stages of culture shock when arriving in a new country. Exaggerated enthusiasm for the new place followed by deep disillusion after a few months, then resignation, then fascination and then finally a kind of loyalty. I think over the past 11 months I have felt all of these things.


welcome sign showing the specialties available at Princess Marina

I definitely agree with the initial exaggerated enthusiasm. When you arrive in Botswana it is incredible. Everyone is so warm and friendly. There are so many new things to explore and everything seems like a new opportunity for something great to happen! But ..….after a few months the seams of your perfect image start to crack and you start to make a lot of realizations. The local people that were so friendly whom you thought would become close friends, never really become friends. You realize that the superficial pleasantries exchanged are as far as your relationships are going to go with most. There’s a wall up that as an expat you are never going to get past. You also realize a lot of things about the culture. Motswana people are very non-confrontational. When you make a request or task someone with an assignment – people will respond very positively with affirmation that they agree or will complete the task. However, you then find that in the majority of cases, nothing ever gets done. It is unclear if the initial affirmation was just a blatant lie or if they were too polite to say that they couldn’t actually do what you were asking. This becomes very difficult in the hospital setting when the things you are asking people to do like give medications, order a test, communicate a result are critically important to the lives of patients.


The Peds Ward

So you realize that if you want to get anything done you have to do it yourself. But then there are so many things that you actually can’t do yourself so you are left in a constant state of following up on every single details of everything you are doing to make sure it gets done. Then after a while when you are just about to lose your mind, you realize you have to just give it up…..and let stuff just not happen because that is just the way it is. This is not a good feeling. As a doctor you don’t want to feel like anything is slipping through the cracks. But in a system like the government hospitals in Botswana, this is the only way you can survive without completely burning out. With this realization comes resignation. You resign your American work ethic and your American standards. You enmesh yourself in the system, which means you accept that some things are shitty and many patients will likely die needlessly everyday. It is terrible but you have to pick your battles. I always feel like dermatology patients are so lucky at Princess Marina Hospital because I fight tooth and nail for my sick patients and make sure they get what they need no matter how long it takes me. But to be able to have the energy to do this, other patients get less than ideal care. It is so hard to find a balance. To decide when to fight and when to let go. Who needs the extra help and who doesn’t. With every prescription I write, I have to think about the fact that there is another person who likely won’t get this medication when they need it because supplies are limited for almost everything. I have to triage everything I do. It is a mentally exhausting exercise that gives you a constant sense of guilt.


random dilapidated equipment can be found scattered about the hospital grounds

I recognize the stage of fascination that has come lately. I am utterly mystified at how interpersonal relationships play out here. Fidelity seems to be the exception to the norm when it comes to romantic relationships. The population is very small so you may often know the person who your partner is cheating with and it could be a friend or relative. This seems to lead to a general air of mistrust and jealousy among women. There is also a very high rate of teen pregnancy, having children out of wedlock, and having multiple children from different fathers as a single parent. All appear to be stigma-free. I find it so interesting that all of this can happen in a very religious society where HIV rates are among the highest in the word. I have no comment on whether it is right or wrong but am very intrigued at what has driven these behaviors to develop and how they have evolved to be totally socially acceptable.

I am captivated by the history of the country. How the poorest country in the world has risen to a middle income country in just 50 years. How and why Botswana is so different than its neighbors. The difference from South Africa is palpable – when you cross the border you can feel the difference. The scars of apartheid are everywhere. Incredible how Botswana set its course completely free of this ideology of hate.

And then there is HIV. How and why did this disease strike so hard at one of the biggest rising stars of Africa in the prime of their era of modern advancement? It is endlessly perplexing why HIV has particularly ravaged Botswana and still remains such a huge problem despite free healthcare, free antiretrovirals and strong HIV programs. I have many opinions on this and am continually probing for answers from my experiences.

And now there is the loyalty which I’m just starting to get to. I didn’t realize how much I actually love my job until the thought of having to leave it came up. It really is true that you don’t know what you have until its gone! When thinking about what we are going to do after the next year, it is hard for me to fathom leaving forever. I’ve just become so accustomed to everything – the freedom, the flexibility, the fascinating pathology you can’t find anywhere else and best of all not having to chart and bill defensively like you do in the US. Despite all the headaches and frustrations it really is an amazing work experience. But my feelings are complicated – definitely often a love/hate relationship – but in the end it is really my patients that I love and I can’t imagine leaving all of them. It will be very sad and very difficult but I hope to find some way I can continue to be involved in working here in the future. I worry everyday about what will happen to them when I leave!


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