© 2018 Dr. M. Sheppard

Botswana Kanye Households People Lands Cattle-post Crafts

On average women of 50 have given birth to 6.5 live children. The main diseases are T.B.. of which 5% of the population are believed to suffer from live T.B. (probably as high as 30-35% in some communities). Venereal diseases are another problem and it is estimated that 25-30% of the population over 14 could suffer from these. In the South bilharzia is another common disease. Measles. pneumonia and enteritis are also problems. During droughts there is malnutrition  particularly in remoter areas and among children of the lowest income groups.

Although many of the early missionaries provided medical help (e.g. David Livingstone was a medical doctor) the first hospital was not built until 1920. Most medical services were developed by the missions. Before 1905 the government only had one doctor. The Protectorate administration only became aware of the health problems in the 1930's and it was not until the 1950's that money could be allocated to provide medical services.

Apart from lack. of finance and a centralized co-ordination, the main problems have been lack of understanding of elementary health care by the population, and the authorities until recently failed to see the importance of a role within their system for the traditional forms of medicine. A recent survey indicated that 90% of the population has at one time or another consulted or received modern medical aid, 40% of the population still consult traditional doctors, as do more than 40% of the close relatives of nurses.

Increased hospital provision was seen as a top priority in the first stage of improving medical services and by the 1980s there were 11 general hospitals, with a total of 1,871 beds, and one psychiatric hospital. There were also 3 mining hospitals and 4 mission ones that were government subsidised. There were 7 health centres, 70 clinics. approximately 100 Health Posts (these received regular visits from qualified nurses and doctors). These services were supervised and co-ordinated by Regional Health Teams. Altogether within the country there were about 75 doctors, 10 pharmacists, 5 dentists, and 700 nurses.

Preventive medicine has been a target area of post-independence health policy. Vaccination programmes have eradicated smallpox, and infants and young children attend clinics to be vaccinated against such diseases as measles, polio and T.B. A Health Education Unit was started in 1974 and attempts to educate people in nutrition, environmental hygiene and increase the acceptability of immunization programmes, also to trace those with communicable diseases such as T.B. and venereal diseases. Another target area has been to attempt to improve services for and attitudes to the disabled.

Western Medicine and Health

This sector of the health services is relatively new to the Tswana when compared to the traditional health services. These services were introduced by the nineteenth century Christian missionaries, although it should be noted that Livingstone was the only missionary with formal medical qualifications. Other missionaries would share their limited medical resources and knowledge, as would the traders. In the nineteenth century the type of medicine available from the missionaries probably differed very little from that of traditional doctors, who probably had the advantage of having a much wider local knowledge of the locally available herbal remedies.

The first government hospital to be established by the Protectorate Administration was of little relevance to the Batswana as it was established at Mafeking. This was around the turn of the 20th century. However, Bangwaketse Chiefs, probably encouraged by their missionary advisers, showed interest in this "new" medicine. In 1906 Bathoen I requested the Protectorate Administration to appoint a medical practitioner to the tribe. This request was not in fact granted until 1911 in the reign of his son SeepapitsoI, another progressive Chief.

The American Seventh Day Adventist mission was admitted to Kanye, mainly because, unlike the L.M.S. who had up to this time had a monopoly on Christianity in the area, the S.D.A. had promised to develop medical services. They agreed that, in return for a monthly tribal subsidy of £50, they would build a hospital to provide the Bangwaketse with free medicines and treatment. This resulted in Bathoen 11 imposing a medical levy on the tribe of 2s per annum per taxpayer.

But some of the tribe objected to this and reported the case to the Resident Commissioner. Schapera (“Tribal Innovators” quotes from the contemporary correspondence to show one of the main grievances:- "... they (the Bangwaketse) resented being compelled to pay an extra 2s to be obliged to go to a particular doctor without any right of selection on their parL" (B.P.J. 1937/1 :RC to HC 18.xi.1930). The Resident Commissioner in fact ordered that the levy should not be imposed because the mission already received a government grant for its medical work to the tribe This was, at least in part, paid for by the Bangwaketse contribution of annual tax.

The S.D.A. hospital developed during the 1930's and was one of the first to be built within the present boundaries of Botswana. The Protectorate Administration, mainly through lack of funds, established few medical services, especially outside the main tribal capitals, but believed firmly that traditional medicine was evil and equated it with witchcraft, both of which would eventually be eradicated through the provision of government medical facilities:- "Witchcraft and the influence of native medicine men continue to play a very important part in the lives of most of the native inhabitants and are responsible for much suffering. It is the aim of the Administration so to develop the medical services that these will be replaced by confidence in qualified medical men." (AR.::8P.1929 - Quoted by Caroline Dennis in Botswana Notes and Records 10,1978:53-66.)

This theory could be neither disproved nor proved until the provision of medical services could be radically increased. Various reports, Commissions of' Enquiry, and the Chamber of Mines constantly noted the need for improving medical services in Botswana, for example, 25% of Batswana potential recruits had to be rejected on medical grounds compared with 5% from other Southern African areas. Following grants made in 1934, a training scheme was set up to train Batswana as nurses, midwives, and dispensers to staff the new recommended clinics and health posts, as a hospital system in such a sparsely populated area had not proved to be a viable way of organizing health services. World War Two intervened and the development of medical services had to be postponed with only four of the recommended 20 dispensaries completed.

In 1957 the Davey Report stated that Dr Davey (its author) “...regretted to say it, but medicine in the Protectorate was little more than vet medicine- it was not an efficient service." The increase in the provision of medical services therefore dates mainly from the tremendous development of the country following independence.

As my research (in the 1970s and 1980s) concentrated on Kanye most of what follows will be with specific reference to Kanye and the Bangwaketse. However perhaps first it should be noted how the modern medical services available in Kanye fit into the national organization of health services, The health services of Botswana are provided by central government, local government, the missions, mining companies, other non-government and voluntary bodies and private and traditional practitioners, It should also be noted that the government often subsidises non-government health facilities for example, mission hospitals and clinics. The country is divided into Regional Health Teams who are part of the Ministry of Health. They aim to provide the link between the basic health facilities and the referral facilities.

Although, as already stated, this research is specifically about the Bangwaketse of Kanye, mention must be made of medical services in rural areas as part of the agricultural year is spent by Kanye residents at the Lands or Cattle-posts. The lowest level of modern health services is the Health Post staffed by a Family Welfare Educator. (F.W.E.) These staff are not fully qualified nurses nor have they necessarily completed 3 years of secondary education. Their job is defined as ".. to be a health motivator and educator in family and community health." They are trained to refer more serious cases to a higher level. Their main function is thus to provide First Aid services and some preventive medicine. (The 1973-8 National Development Plan (p.287 ~ 14.13) outlines this type of personnel. "A woman is selected from within a village, and given a training of 10 weeks in the rudiments of personal and public health, nutrition and health education, child care and family planning. She is also taught how to recognise and treat a few simple diseases, such as scabies, how to identify and cope with malnutrition in children, and how to follow up T.B. patients and their contacts.")

Health Posts are found throughout the rural areas of Southern District. During the 1970's and 1980's the target has been to locate these in such a way that everyone should be within reasonable walking distance of a health post or the next level of service, the clinics. (1976-8 National Development Plan stated that there were 177 health posts in Botswana, 40% of which could be described as having adequate buildings and equipment. Health Posts are regularly visited by qualified doctors, nurses and/or Medical Assistants on tour.)

Clinics provide the facilities of a health post but in addition provide a wider range of educative health subjects, carry out immunizations, and may have up to 6 beds for curative and maternity care. They are staffed by Family Welfare Educators, nurse aides and at least one qualified nurse who has undergone a midwifery course. They also receive periodic visits from doctors and refer more urgent and emergency cases directly to the next level - the health centre or district hospital. The 1978-9 Annual Report of the Ministry of Health stated that in Botswana there were 33 clinics with maternity beds and 59 without such beds, For both types the majority were run by the district councils.

Health Centres are designed to duplicate on a small scale most of the simple curative functions which are usually provided at hospitals. They also provide maternity and preventive health care. There were 7 of these mentioned in the 1978-9 Ministry of Health Annual Report. 6 were run by the District Councils and one by a mission. The District Councils also run and oversee the day-to-day operation of the clinics and health posts, but receive financial grants from central Government.

The highest level of district health care is provided by the district hospitals. These may be either mission or government or mining, but all are either directly run by the government or receive substantial government finance.~ There were 13 of these district hospitals, and Princess Marina Hospital not only acts as the district hospitals, and Princess Marina Hospital not only acts as the district hospital for the Gaborone area, but is the main national referral hospital. It has specialist equipment and specialist medical practitioners not necessarily available on a daily basis at district hospitals. Psychiatric cases requiring in-patient treatment were referred to the Specialist Psychiatric Hospital in Lobatse.

In Kanye, the Western-orientated "modern" health services consisted of a 167-bed hospital which run by the S.D.A. Mission. In the 1980's this hospital was utilizing a large grant from America and work was commenced in 1982 for extensive rebuilding and extension. This hospital provided most of the general services of a hospital. It had an operating theatre, T.B. Wards, maternity ward with facilities such as incubators for dealing with premature and delicate infants, eye and dental clinics, specialists from Princess Marina and other  hospitals visited periodically, and the more complicated cases were referred direct to the greater range of specialist facilities in Gaborone at Princess Marina Hospital, or to Baragwaneth Hospital in Johannesburg.

Apart from providing in-patient treatment, there are daily out-patient clinics to which a sick person couldl go initially. Here patients would be examined mainly by the duty nurses and/or hospital assistants who would prescribe and administer treatment as necessary, or call the doctor on duty if the case was more complicated. A patient requiring in-patient treatment would be admitted from a clinic.

The emergency cases outside clinic hours were dealt with by the duty ward staff, a doctor being called if necessary. Home visits to bedridden cases were not usually made, such patients were brought by relatives to the hospital. A hospital ambulance could be hired if necessary but many patients arrived by locally hired or owned transport such as cars, pick-ups, tractors, ox wagons, donkey carts etc.

The S.D.A. Hospital also provided family planning facilities. .However it should be noted that because of the mission attitude, which was contrary to stated government policy, unmarried people found it very difficult to obtain such facilities at the mission clinic. Preventive medicine was also administered at special clinics, for example, various injections.and inoculations such as cholera, typhoid, tetanus, polio, B.C.G. These were free and available on demand.

Apart from the fairly comprehensive medical services provided by the hospital there was also a government clinic staffed by qualified staff (trained nurses, nurse aides and F.W.E.s) and visited weekly by a doctor. They referred urgent cases to the S.D.A. hospital, but specialised in providing ante-natal, post natal, infants' and young childrens' clinics.

The staff at both the hospital and government clinics attempted to educate especially mothers and pregnant women in nutrition and child care. At the government clinic the staff ran a demonstration vegetable garden. In addition there were F.W.E.s who mainly seemed to specialise in tracing patients with T.B. and venereal diseases and their contacts.

Additionally there were private practitioners. The hospital ran a private service with daily clinics. Patients who could afford this service often preferred to pay, as this ensured seeing a doctor, and a greater range of drugs appeared to be available. The general clinics charged a national standard 40 thebe per course, the private clinics cost from approx. P3 upwards according to the problem. Admission to hospital was  a few thebe per night in the general wards (private patients could be admitted to these) or PI -2 per day in the private rooms.(N.B. Most in-patients have food brought to them 3 times a day by relatives. The hospital food, although available left much to be desired.) From the early 1980's there was an additional private practitioner in Kanye. Although he was more expensive than the hospital private service he was popular with those who could afford to pay. even though he had to refer his cases to specialists in South Africa.

In addition many patients who could afford it were prepared to travel to Lobatse, Gaborone or any of the other urban centres or hospitals to see doctors privately. As stated by other researchers Batswana favour medical services according to empirical evidence, i.e. if a particular doctor or hospital has a good reputation for curing a certain health problem patients will try their utmost to go there.

For example Kanye S.D.A. hospital was not favoured for dental extraction, the medical assistants had a reputation for painful work. Princess Marina, on the other hand, had a much better reputation in this field.

The Bamalete Lutheran Hospital at Ramotswa had a good reputation and people were prepared to travel there involving at least three changes of bus. A certain private doctor in Lobatse had the reputation for successful treatment of infants and children. On the other hand it should be noted that many people travelled from other districts to the S.D.A. hospital in Kanye and the new private practitioner. Perhaps these factors should be seen within the context of how people would often (and still did) travel long distances to see traditional practitioners, often ignoring the locally available practitioners.

Probably one could generalize by saying that modern facilities are available and accessible for those who want them and, as has been noted in other developing countries. are often cheaper than traditional services. The charges noted above for "modern" services were often much less than those of a traditional practitioner who charged 50 thebe- P1.SO for throwing bones, and several pula to as much as a bovine beast for treatment. Therefore what about the belief of the Protectorate Administration mentioned above that once the medical services were increased, the population would no longer require the services of traditional practitioners? By the 1980s the medical services in Botswana were developed enough and accessible to test this 1929 assertion

A 1970s study noted that 93.4% of the population had at some time received modern medical facilities (i.e. such services are widely acceptable to the population). However at least 43.9% of the population also used traditional facilities (43.7% of those with close relatives who were nurses). This showed a picture similar to other countries where there is a choice of type of medical facilities - and in making a choice people will rely on empirical evidence. If modern facilities appear to be successful in treating a condition they will go there, if a traditional practitioner is successful they will go there. In many cases they might visit both as, although modern facilities are recognised as curing a medical condition, as noted in the section on traditional medicine, this may be seen by traditionalists only as alleviating one symptom of a wider problem that requires treatment from a traditional practitioner.

Some of the medical conditions commonly brought to the Western medical services with special reference where possible to those in Kanye.*1  The 1978-9 Annual Report of the Ministry of Health *2 indicated that during 1979 64,953 patients and 17,200 normal new born infants (i.e. a total of 82,153) were discharged from hospitals, health centres and clinics with maternity wards. By examining the individual discharge summaries (available for 96.4.%.) of these discharged patients it is possible to see a pattern of common health problems brought to the “modern” medical services. The Ministry of Health Report classified the results according to diagnosis, age and sex and used the Basic Tabulation List categories of the 9th Revision of the International Classification of Diseases (W.H.O. Geneva 1977). General Conclusions showed that Injuries and poisonings accounted for 9.8% of the total and was the single most frequent cause reported. Direct obstetric conditions was next with 6.6% of the total. Intestinal infections accounted for 5.5% and T.B. For 5.3%. Conditions originating from the perinatal period accounted for 5.1%, abortion 3.1% and measles 3.0%, pneumonia 3.0%, diseases of the circulatory system 2.9%, bronchitis, emphysema and asthma 2.1%.

Therefore about one tenth of all discharged patients had been treated for injuries and poisoning, one tenth for complications connected with pregnancy, childbirth and the puerperium. Intestinal diseases including diarrhoeal diseases, T.B. measles and respiratory diseases are the major causes of morbidity. Looking at mortality statistics in hospitals, clinics, and health centres, T.B. is the major single cause, accounting for 20.5% of all deaths. Perinatal causes are second (13.8%) and diseases of the circulatory system account for 10.9%, with intestinal infections accounting for 10.3%.

The conditions obviously vary according to age group. For example about 80% of all deaths and 75% of all discharges of infants are accounted for by intestinal infections and perinatal conditions. In the 1-4 age group intestinal infections (mostly diarrhoeal diseases) accounted for 19.7% of all discharges and 10.5% of deaths. If children under 5 are taken as one group (they accounted for 20% of all discharges and 40% of all deaths) the main health problems are perinatal causes (25% of all discharges, 33% of all deaths), intestinal infectious diseases, measles, pneumonia, and injury and poisoning. These five causes accounted for above 66% of all discharges and 75% of all deaths in this age group.

In the 5-14 age group 27.1% of all disch~rges were cases of injury and poisoning, next follow measles, T.B. and pneumonia respectively. These account for 50% of all discharges. In the 15-44 age group normal confinement accounted for 60% of discharges, 10.9% were cases of direct obstetric causes, injury and poisoning 7.7%, abortion 5.2% and T.B. 3.7%. Mental disorders accounted for 1.6%.

In the 45-64 age group, T.B. accounted forI7.7%, injury and poisoning 13.6% and diseases of the circulatory system 13.5%. It should also be noted that mental disorders accounted for 2.8%. For those over 65, diseases of the circulatory system were the highest reported health problems, accounting for 17.2% of the discharges, T.B. 16.8%, diseases of the eye and adnexa 9.8%, and injury and poisoning 9.0%. Mental disorders were lower in this age group accounting for 1.4%. Thus it can be seen what are the main reported health problems according to age group dealt within the modern health sector.

Something should also be noted of the" relative numbers per age group as this perhaps shows the in-patient age character of the modern services. The 1-5 years accounted for 11.2% of total patients, 5-14 accounted for 7.98%, 15-44 accounted for 58.3%, the 45-64 for 7.1%, and che over 65's for 3.6%. This therefore gives a picture of a modern health service that provides a service particularly for the 15-44 age group. There are also indications that it is not popular with older people i.e. those over 45. The similar statistics available on outpatient clinics are not so reliable but indicate that in 1976-9 25% of all patients suffered from respiratory infections, this was followed by skin infections and gastro-enteritis, and worm infestations seemed to be on the increase. The three-fold increase from 1978-9 in the cases of malnutrition reflected the increasing effects of the drought of that period.

If one looks at some of these sickness causes in more detail it can be seen that 10% of all discharged patients in all age groups suffered from injuries and poisoning. Here fractures were the greatest single cause, th€ highest incidence of cases being found among males in the 5-14 age group who had 19.6%of all fractures. Males of 15-24. 25-34, 35-44 and 45-54 also had higher levels of fractures than other age groups or their female counterparts. This might possibly be accounted for by the fact that these age groups cover those working in the mines, and who are most active in physical activities involving risk, for example, working with oxen, roofing etc. If these age groups are taken together they represent 41.3% of all fractures. Burns also fall into this category. Here those most at risk are the 1-4's and 5-14's. This is doubtless because of the fascination that fire always holds for children, also that young children often like to imitate adults by attempting to cook. These groups represent 64.5% of the total cases of burns.

With regard to poisoning and toxic effects, the age groups where there is the most frequency of cases are again, as would be expected, children. The 1-4's had the most cases, followed by the 5-14's and the IS-24's respectively. Children under 15 had 57.3% of the total number of such cases and young people (15-24) had 14.6% of the total.

Mention can be made of other diseases according to age group and sex. In all diseases affecting children, boys show a greater number of cases than girls, i.e. intestinal infectious diseases, measles, nutritional deficiencies, pneumonia, chest diseases, for example, bronchitis. The cases of T.B. reach a peak in the 35-44 age group having started to rise in the 5-14 age group. V.D. was most prevalent in the 15-34 age group who have 56.7% of the total cases.

Nutritional diseases were most prevalent among the under fives (78.6% of total cases). Mental disorders are found among the 15-44 age group (67.0% of the total). Hypertensive diseases are most prevalent among those over 35 with an increase in incidence with age (75.9% of all cases)t women being more affected than men in all age groups having 61.5% of all cases.

Diseases of the circulatory system also increase with age, the over 65's have the highest incidence. The greatest single cause for women to become in-patients is all conditions associated with pregnancy. Here, as would be expected, the 15-34 age groups are the most affected.

Passing reference has been made  to a Mental Health Service in Botswana. This consists of a Psychiatric Hospital at Lobatse which in 1979 admitted a total of 727 patients and discharged 1047. Of those admitted, 465 were male and 262 were female. In addition to the Lobatse Psychiatric Hospital there were Mental Health out-patient clinics. These clinics were planned in the 1976-81 National Development Plan and aimed to detect, report and refer necessary cases for in-patient treatment. These were based at the larger clinics and district hospitals.

In 1979 The Kanye Mental Health Clinic saw a total of 218 cases, of which 80 were men and 138 were women. The main mental health problem was classified as schizophrenia affecting 56 men and 70 women. 6 men and 28 women were suffering from neurotic disorders (unspecified) and 15 men and 19 women from epilepsy. There was no regional breakdown of the cases available for Lobatse Hospital in-patient cases, but here again statistics show that schizophrenia was the greatest cause with 125/441 men and 85/247 women reported as suffering from it. Epilepsy showed 28/441 men and 11/247 women. Perhaps it should be noted that the statistics showed 198/441 men and 108/247 women were admitted for observation. Therefore no more than generalizations can be drawn from these available statistics.

The above statistics available for physical and mental health must be used with caution, as obviously not all cases of sickness are brought to the attention of, and for treatment by, the "modern" health services, the percentage brought probably also varies with age. However these statistics are perhaps able to indicate in a general way the common prevalent diseases and also those that Batswana judge as able to be treated by "modern" health facilities

THE "MODERN" HEALTH SERVICES