I’ve spent the last few weeks trying to figure out the deal with the home and community based care (HCBC) I’ve been told was at the heart of palliative care here. After getting lost in Princess Marina Hospital and multiple unreturned phone calls, I decide one day to start at the top and wouldn’t stop until I found someone willing to explain things to me. I started at the Ministry of Health, a towering building of exposed steel at the far end of the government complex. I stride inside, ask my question. I’m told to go to the Ministry of Local Government, a shabbier brick building right across the street. Entering, there’s a cluster of men around the front desk. I say “dumelang,” somehow implying I speak fluent Setswana, and I’m immediately lost in a mess of foreign syllables. My terrified face provokes a laugh and I’m told to go “over there,” a finger pointed to a point far off.
I wander in that general direction, doubling back as some unemployed men outside the district labor office point in the opposite way in exchange for a few pula. Once I’m certain I’ve seen every possible government building, I ask another woman and she gives me the first concrete direction: It’s next to Masa.
Those of you unfamiliar with Gabs, if there’s one place every foreigner knows, it’s Masa. It’s an upscale hotel in the Central Business District basically built for well-off foreigners.1 Unfortunately, it’s another 30 minute walk away and the early cool has given way to a redhead scorching, midmorning sun. I arrive sweat-soaked and disheveled. There’s another pause while folks figure out exactly who will have to deal with me. After a pause, a very kind woman informs me that here, they just issue the top level policy, that I should go to the Gaborone City Council (GCC) to see how HCBC actually works. I try to explain that I’m interested in the top level policy, that it will inform how I see the day-to-day, but it’s clear I’m being shown the door. I get a copy of the policy and leave. The GCC is back and past where I came from, and I’m already tired.
I’m also told I should write a brief letter explaining who I am and what I’m doing, in case this blog becomes a viral hit and the HCBC staff at the GCC needs CYA. Given that it’s lunch and governments around the world shut down for meals, I grab a cup of coffee and type something at Masa. On my long walk back, I grab a quick bite to eat and find a print shop. Arriving at the GCC, I see a sign indicating HCBC is in Block B, Office 27. Jackpot. I ask someone finishing their lunch for directions. “Oh, it’s right over there.”
So it goes.
The GCC is a set of L-shaped building laid out doorway to doorway in such a way that at any given moment, it’s impossible to ascertain where I am in relation to any other place. I wander for thirty minutes, passing up promising offices for the sake of the foretold Office 27. Not once do I see an office below 35.
I decide to double back and try one of the earlier promising options. Unfortunately, the Escher-esque layout leaves me scrambled and confused. I retreat to the front and start over, stopping at the first office with the word “social” in its title (Offices of Social Welfare, 60-65). Confused office workers try to find the secretary to help me out, but she’s still at lunch. In a moment of serendipity and proper paperwork, my letter winds its way to Flax Setlhare, who, while confused what the hell this kid is up to, seems willing to humor me.
Flax is the principal social welfare officer, placing HCBC under his jurisdicition. He explains that HCBC is limited to a fairly small pool of patients. They try to get most people get back to work, negotiating with their employers for accommodations or limited hours. Alternatively, they provide “life change counseling,” encouraging people whose capacities have drastically changed to “participate in finding decisions.” To be strong enough for survival, you need someone to push you, Flax tells me as he lightly shoves my shoulder.Fields of sage on the road to Kasane
But what about those individuals who really can’t return to work? People who cannot stand on their own, who are listed by the Ministry of Health as unable to be employed, receive HCBC. Flax’s department provides a monthly food basket, refers folks to appropriate services across the government, and can help with schoolkid’s tuition, while the Ministry of Health provides rehab equipment.
While all good, it seems fairly limited. Certainly, counseling from social workers and referrals are valuable services, and as Flax says “food is medication,” but some people need more. There are bandages to change and medications to monitor. Regular medical check-ins can make a world of difference. For those needs, Flax says, they work with hospices and NGO’s that provide more substantial home based care. Hospice daycare programs give relief to caregivers, while the the hospice volunteer networks can provide an extra layer of day-to-day support.
Unfortunately, Flax acknowledges that these groups are full of “tired people,” overworked and dependent on scattered donations. There just aren’t enough resources right now for all that they might be able to do in communities. He hopes in the long run the GCC might be able to offer financial partnerships with these organizations, but right now it’s not the top priority.
Despite my wanderings, I still haven’t seen home based care in action, just a narrative of its potential. Luckily, my host in Gabs knows the chairperson of the Botswana Retired Nurses Society (BORNUS), one of the major NGOs providing Home Based Care. I’m invited to drop by for a chat and a few patient visits. And this time, I have a ride.
1. The Central Business District itself is a bit of a misnomer, other than Masa and a couple other buildings it’s untouched brush. One of those zoned spaces the market has not yet developed to the point of serving its purported purpose. ↩