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Dr. Dipesalema: Talks on care for babies

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Senior Lecturer and Consultant Paediatrician/Paediatric Endocrinologist Dr Joel Dipesalema discusses paediatrics, a branch of medicine that deals with the care of children.

What is your job and what does it entail?

I am a specialist in Paediatric Endocrinology and I am also a medical lecturer at the University of Botswana. Paediatric Endocrinology is a specialty which deals with hormonal disorders in children and young adults. My daily work entails the provision of clinical services to hospitalised children as well as those who attend the outpatient clinic for consultation with hormonal problems. I also provide medical education to the doctors in training, both at the undergraduate and the post-graduate levels.

What made you decide to become a pediatrician/paediatric endocrinologist?
Paediatrics is an interesting specialty in the sense that as Paediatricians, we grow with our children. We see them going through childhood all the way until they become adults and contribute to the work force and the economy itself, that on its own is very emotionally rewarding when you see the fruits of your success, becoming the pillars of our society.
Hence I chose Paediatrics/Paediatric Endocrinology as a way of giving back to our community by building a strong foundation through the children. Give them good health and they will in return give us a stable and prosperous future Botswana. Additionally, the study of Paediatrics/Paediatric Endocrinology requires a very good background in physiology, biochemistry, anatomy in addition to sociology and psychology. This helps service providers to better understand the physical, social and psychology aspects of care which may affect the wellbeing of the child; and those subjects were my favourite.

What common conditions or problems do you help children with?
As a Paediatric Endocrinologist, the most commonly encountered conditions in my patients are type 1 diabetes mellitus, stunted growth due growth hormone deficiency, overactive thyroid gland, underactive thyroid gland, childhood obesity, ambiguous genitalia(disorders of sex differentiation), adrenal insufficiency, diabetes insipidus, early puberty, delayed puberty, rickets, brittle bone disease, imbalance of the body salts and syndromic disorders. Majority of the cases admitted to the ward have respiratory and gastro-intestinal disorders.

And the most common procedure you often have to undertake?
As hormone specialists in children, the most common procedure we undertake is the hormonal stimulation test as way to make a diagnosis for hormonal deficiencies. For those children who are failing to grow, we carry out the clonidine or insulin stimulation test in order to diagnose the growth hormone deficiency. We also carry out the arterial blood gas sampling for our type 1 diabetes patients who get admitted with diabetic keto-acidosis. Other common procedures performed in Paediatrics include the lumbar puncture, blood culture, urine culture in order to exclude the infections which are quite common at this age group. We also do the radiological investigation like MRI of the brain for suspected pituitary deformities.

Can you share the most satisfying case you have dealt with in recent years?
The most satisfying case I have dealt with is that of a girl who was referred to me at the age of 16 years for failure to grow and attain her periods. She was the shortest girl in her class and she was the only one who has never attained her first period. I carried out specialised investigations and I made a diagnosis of “Multiple Pituitary Hormone Deficiency”.
This is a condition where there is a deficiency of two (2) or more hormones from the anterior pituitary. My patient lacked growth hormone, which explained why she was very short. In addition, she lacked the sex hormones namely Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH) which explained why she did not get her periods.
She also lacked internal body steroids and thyroid stimulating hormone. We started her on hormone replacement therapy and she managed to reach a full adult height and puberty. Her quality of life improved, she attended college and got her qualifications. That was emotionally rewarding to our team to take that journey with our patient and see her grow into an adult who eventually contributed to our work force.

What advice would you give to someone looking for a Pediatric Endocrinologist for their child?
Just to let them know that the paediatric sub-specialties are now available in Botswana, currently we have two Paediatric Endocrinologists based at our tertiary referral centre at Princess Marina Hospital/University of Botswana Faculty of Medicine.
Not so long ago Batswana had to travel outside the country to access that service. We work by receiving referrals from the local general doctors or paediatricians. So I advise my fellow citizens that if they have concerns, their first point of contact is their local doctor who will recommend the appropriate specialist referral for their children.

What are some of the challenges pediatricians face in their job in the country?
– One of the biggest challenges for Paediatricians practicing in our set up is the resource limitations where one has to improvise in order to provide care for his/her patients.
– Shortage of drugs and poor chain supply are one of the biggest hindrances to service delivery in Paediatrics.
– Inadequate manpower to deal with some medical conditions which need specialised care; for instance, the country has no Paediatric Nephrologist.
– No-specific presentation of some paediatric conditions may result in the misdiagnosis of some of the conditions which can compromise the welfare of the children.

How do you see the role of paediatricians developing in the future?
Paediatricians are essentially the cornerstone of our country’s health system as they look after the children and the children are the future of the country. Paediatricians are here to safe guard and reduce infant mortality rate and improve the overall wellbeing of the children so that they grow into responsible citizens of this country. So going into the future, the role of Paediatricians will be in demand.

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Know Your Specialist

Caroline Gartland speaks on Children and Mental Health

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Tell us about yourself and your background
I’m originally from the UK but have been in Botswana for eight years so this is now home! I have a Combined Honours degree in Psychology an MSc in Mental Health and have had a pretty varied career.
I started off working with offenders doing rehabilitation programmes; went on to support the victims of domestic violence then ended up working in Child and Adolescent Mental Health Services for the National Health Service.
I’ve done a lot of work, mainly voluntary, in different fields since being in Botswana but my passion is now Early Childhood Mental Health.

What does your work entail?
Early childhood mental health is mainly working with parents, caregivers and teachers to help them understand how children develop and the best ways to support their mental health and brain development as they grow. It’s about providing training and opportunities for families to bond with their children and introducing new ways of playing and interacting.

What sparked your interest in early childhood mental health?
Quite simply, having my own children! My daughter was born five years ago and I was fascinated watching her develop and grow. It occurred to me that the younger you begin to consider mental health and provide tools for resilience against life’s adversities, the better outcomes you are likely to have.
I began reading everything I could get my hands on, and completed a diploma in Infant Mental Health. I’ve worked down the lifespan but I feel I’m now where I belong, working with babies and young children.

What mental health issues have you observed in children in Botswana?
Mental Health is still stigmatised around the world and Botswana is no exception. Most people immediately think of mental illness, but mental health is about so much more; we all have mental health and some days we are fine and able to deal with life’s challenges and some days we need more support and tools under our belt to help us cope.

Young children can experience mental health problems. Anxiety is a common one, but we are more likely to focus on the behaviour we see rather than how the child is feeling. An anxious child who refuses to go to school may be labelled as ‘difficult’ or ‘naughty’ but what they are expressing is a painful emotion that they need help dealing with.

Describe one thing you find fulfilling and challenging about working in this industry.
Working with children and families is a pleasure and a privilege. To make life a little bit easier for someone is all that matters, you don’t have to be out there saving the world to make a difference.
My major challenge is time. I would love to do more, I’d love to do an MSc in play therapy and a couple of other therapeutic techniques I’ve come across in Europe but that gets put on hold as I focus on my own family and business.

Can you share an anecdote about how mental health consultation works?
I think that education, understanding and connection are the three keys to giving a child the best start in life. Led by that, SensoBaby provides classes in the community for parents and caregivers to connect with their infants.

We offer workshops on parenting and play to foster understanding of child development and wellbeing and we are available to troubleshoot specific problems an individual or agency has with the young children in their care or the systems they have in place. When it comes to individual parents, mostly what they need is to feel heard, supported and guided in their parenting choices.
You can read all the baby books in the world but they won’t give you the answers you need for your child, through responsive parenting and connection, you’ll find you have the solutions you need.

What advice do you have for child-care providers or early childhood teachers who are at their wits’ end over a child’s challenging behaviour but don’t have access to a consultant?
Empathy is an important and undervalued skill – the ability to consider another’s viewpoint. What is that child feeling? Their behaviour might be challenging and hard to deal with but often the root cause is an unmet need. There’s a famous quote from an American Clinical Psychologist, “The children who need love the most, will ask for it in the most unloving ways.”

Does a mother’s mental health affect her foetus? How important would you say is paying attention to women’s well being during pregnancy as with their physical well being?
100% yes. It is so important to support a woman’s wellbeing during pregnancy. As an example, if the mother experiences significant stress and rising levels of cortisol (the stress hormone) during pregnancy, the foetus will be affected and in some cases will be more sensitive to stress in childhood or later in life.

Pregnant women and new families (Dads as well!) deserve nurturing care themselves and shouldn’t be afraid to ask for support. SensoBaby run FREE monthly coffee mornings to support pregnant and new mothers because we understand the importance of maternal wellbeing.

Do smart phones and television make our children mentally ill as is often purported?
I don’t think technology is always the villain it’s made out to be. The key is in the relationship with that technology. Moderate use of TV’s and smart phones are fine, as long as they aren’t a substitute for outdoor play, imaginative play and meaningful interactions. If a child is crying or upset and we hand them a device to keep them quiet then we have missed an important opportunity for connection, helping them process what is going on and supporting them to calm down and settle themselves.

Now, I know you are involved in an exciting programme that helps caregivers and children to bond and get the children off to the best start in life through play. Can you say a little bit about that work and just how you are seeing it play out?
SensoBaby is our baby; a project born from passion and a desire to support families in Botswana. We offer play-based classes for children and their caregivers that are underpinned by the principles of child wellness as well as early foundations for learning.

When you provide developmentally appropriate opportunities to play, you learn so much about your child. That understanding and observation builds strong connections, which will form the basis of that child’s future relationships and self esteem. Play is so much more than ‘a fun activity.’

We offer a number of trainings and workshops for parents, nannies and community stakeholders and hope to increase our offerings this year. Our community partnerships and voluntary programmes have been successful so far and we hope to see more impact in 2018.

We currently serve the Gaborone community but would like to expand throughout Botswana as opportunities arise. The response to SensoBaby has been fantastic so far and we can’t wait to see how far we can go with the concept!

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Know Your Specialist

Terence Mohammed explains intricacies of clinical trials

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What does a lab manager do?
As BHP laboratory manager, I am responsible for providing an oversight in the technical operations of the laboratory, including the clinical trials processing and testing labs. As part of the laboratory management, I also provide leadership in planning, implementing and completion of research activities and to ensure that laboratory operations and data generated is in accordance with Good Clinical Laboratory Practice. The lab manager is also expected to provide an oversight on the laboratory quality management system and laboratory expenditure.

Describe your career trajectory. How did you get to where you are now?
I joined BHP in 2007 as a laboratory research assistant. I worked for two years in various BHP clinical trials for diagnosing and monitoring of HIV/AIDS in clinical trials participants. In 2009, I got transitioned to the BHP research laboratory to work as a research fellow where I got assigned to work on various basic science projects. In 2014, I worked as a research laboratory coordinator where I was mainly involved in day to day routine management of the research laboratory activities including; conduct of research projects, preparation of education activities and mentoring of new research fellows, students and interns. In 2015, I got promoted to the position of deputy laboratory manager where I assisted the lab manager in overseeing the technical operations of the lab. In 2017, I got promoted to the position of lab manager.

What’s a typical day/week at the Botswana Harvard Partnership (BHP) for you?
I participate in a lot of weekly meetings; laboratory management and departmental meetings. I am also expected to attend meetings for the various clinical trials which we provide laboratory services to. These include local site meetings and international conference calls with study principal investigators and sponsors. I also review and authorise laboratory orders ensuring continuous operation of laboratory work and within allocated budgets. In addition, I also allocate time to walk around the different laboratory departments on a regular basis in order to interact with staff and learn more about their challenges. This facilitates discussions on how to improve our laboratory operations and working environment.

What are the main health and safety issues for lab technologists?
Exposure to blood, bodily fluids and tissues, which may contain infectious agents and also exposure to ultra-cold materials such as liquid nitrogen and dry ice. However, all necessary laboratory safety trainings are mandatory and staff has access to personal protective equipment including lab coats and gloves which are a requirement for certain tasks.

What aspects of your role do you enjoy the most?
I enjoy the daily interaction with researchers in the field of HIV/AIDS, both locally and internationally. It makes me proud to be part of a team that is working towards ending the HIV/AIDS pandemic in our region as it has decimated the population for over two decades now. With our work, I hope Batswana become increasingly cognisant of the task ahead of us and unify to bring an end to the pandemic.

What would you say the biggest challenge in your field is? Discuss one thing in particular?
Supply of laboratory reagents and consumables can be challenging as sometimes we experience supply stock-out and delays in delivery.

On a basic level, what skills does your job demand?
A lab manager should be able to organise and run effective meetings. It is important to set up an effective meeting agenda and be able to assign key action items to staff
-To be able to communicate effectively and create a positive atmosphere in the working environment. It is also important for the lab manager to be able to motivate staff and also be approachable to staff whenever required.
-A lab manager is expected to have leadership skills in order to provide direction to team members and ensure that the institution goals are effectively met.
-To be able to manage budgets and always be alert to ensure that the laboratory current spend does not exceed target spend.

You have done some research on HIV-1c gp120 in recently and chronically infected individuals in Botswana. For starters what is HIV-1c gp120? A brief background on the research and what the findings were?
Gp 120 stands for glycoprotein 120. This is a protein found on the outer surface of HIV and it used by the virus to enter human cells thereby causing infection. Previous research has shown that gp120 characteristics and properties could be susceptible to change overtime during the progression of the disease. Therefore, we used two groups of study participants at various stages of disease progression (i.e. recently and chronically infected) to see if there are changes in structure and properties of gp120 during the course of the disease. This research highlighted the need to further investigate gp120 in order to get information that maybe useful in the development and designing of an effective vaccine

What advice would you give someone interested in becoming a research fellow?
I would advise them to read a lot in their field of interest and also be aggressive enough to seek opportunities of attachment to a relevant institution. Furthermore, they should seek to interact with experts in the field in order to keep themselves in the loop should a research fellowship become available.

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