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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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Kutlwelo Mariri ready to diffuse special needs children time-bomb

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Without sufficient funding and a more coherent approach, the future of children with special needs is bleak according to Speech-Language Pathologist (SLP) and Audiologist and founder of Ambrose Academy, Kutlwelo Mariri.

She was one of the eighteen young leaders from Botswana who flew out to the US recently to participate in the Mandela Washington Fellowship, the flagship programme of the Young African Leaders Initiative (YALI). Here she discusses her experience and what she has learnt through the programme.

Why did you apply for Mandela Washington Fellowship (MWF) Program 2018?
As a person you need professional and development growth so this was opportunity for me to go and appreciate how far I have contributed with the field of Speech-Language Pathology and Audiology in my country, to learn about the business acumen of making services sustainable and to see what’s next. So since I heard how rich the Business and Entrepreneur track was I believed I should apply and I really got more than what I ever bargained for. It was an experience I wouldn’t trade for anything.

What does it takes to be Mandela Washington Fellow?
It takes a person who has the willingness to change the status quo as well as to care about improving the lives of people. In a nutshell you should be a visionary. I think for last year there was about 37 000 applications and total selection been 700 in Africa as a whole. We were only 18 from Botswana and I was privileged to be part of the Botswana MWF 2018.

What did it mean for you to be selected?
You know Rachel, God’s timing is always the best and we never understand it. I have been meaning to apply but our organisation was not ready for me to go away for 7 weeks so this time I applied and was selected this was perfect timing for me as well as our organisation. For example from the professional side of things we needed to re -evaluate our journey and reposition ourselves to continue being of value to the patients and to special needs children as well as introducing PREVENTION IS BETTER THAN CURE. One of our major concerns is that many children are delayed in speech and language, in fine and gross motor skills simply because of lack of stimulation if we do not attend to this, the number of special needs kids will continue to rise. So as Ambrose Academy we need to address this issue like yesterday otherwise we are sitting on a time bomb.

Where were you placed?
I was placed in a very intensive programme for 7 weeks in University of Austin, Texas under the programme of leadership headed by Professor John Dogget. From the very first day, he told us his intent was not to make us into himself, rather to make sure we graduate from the programme as people who will go and make a difference in our countries and make Africa what it needs to be. He has deep care for Africa and I feel like I owe it to him to make sure whatever I have learnt I better myself and my people. The course covered main areas of leadership, business, critical thinking, self care and this year’s Mandela Theme of Servant Leadership.

So how do the following areas apply in your profession;
Leadership-As you know the profession of Speech-Language Pathology and Audiology is relatively a new profession in our country we still have a long way to go. However what came from the MWF 2018 was that do it in phases, appreciate where you are, where you need to go and keep pivoting until you get at your destiny. Be willing to get advice and be eager to learn so that you keep up with latest trends in your field and NEVER compromising QUALITY.

Also care about humanity and the people you serve as much as acknowledging that some will NEVER be happy with your services no matter how much you try but make peace with that. This really resonated with me very well I always see possibilities with my adult patients and special needs children however one thing that used to hurt me is seeing a parent with buying power not affording their child that opportunity and always complaining about this and that no matter how much I tried.

Business Acumen-Please allow me to generalise in Botswana , there is perception that Health should be FREE even in private sector while its OKAY to pay it in South Africa for example and that has robbed us from having research institutes because research is expensive. In most cases I struggled so much with my patients wanting discount of everything which then makes it impossible to pay monthly expenditure like the rentals and salaries of the personnel. So I heard in all the 7 weeks that passion alone won’t pay bills every day. Prof Doggett made sure we get that. He summarised it like government, private sector even Non Government Organaisations need funds to run. So it doesn’t matter what for, whether for rehabilitation to improve, we need funds to make it first class like in other countries. So sustainability comes in here; if one can’t pay for running cost then they simply face closure.

Self care-Everyone who is in business will attest that as a founder or pioneer of any project you work non-stop with absolutely no time to smell the coffee. This really puts one at risk for cardio vascular diseases and burn out as all they do is work, work and work. However I have learnt to appreciate that one needs to take care of oneself before taking care of other people. All I have been doing is work, work and work. I used to love baking and for the past 7 years I never did it so at least now I have started to learn again, hehehe maybe this festive season I will bake for my family …..
Servant Leadership-I believe as Africans we have the custom for servant leadership it comes natural to us to care about each other even those in the community however we have diluted this if not lost it.

That is why we have concept such as Kgomo ya Mafisa or every child is yours …… Every child is yours really hit me home when my team and I saw the need to establish a trust that can raise awareness about special needs children or teach the public about rehabilitation it was a way of giving back…..there is so much stigma but the question what do we do about it? Do we advocate for these kids or we turn a blind eye we concluded that we needed to advocate so that whether in government, private sector or NGOs our people can be helped. But our many challenges are that there is no volunteerism anymore, we only care once it hits home and by that time there is nothing much you can do because now when you advocate you fear people will say Oh you are only doing it now because you are going through it even though I personally believe it’s never too late to start.

You touched on the general expectation by most people for free medical/specialist services and you raised valid points. But, what of special needs children coming from underprivileged backgrounds? Are we saying they are doomed because their parents can’t afford specialist services at Ambrose Academy for example?

Oh my God Rachel, this is one area that hurts me the most, it’s just that my hands are tied. You know we are very far from assisting these children. I always say if we the literate ones, with buying power and with so much exposure; we don’t see the value of investing in our children ‘s rehabilitation services or prevention is better than cure programmes what is the possibility of having these services extended to those in deep rural areas? Because once we get it then we will extend it to them and fundraise for them? Until then I don’t know what will happen, we need brave people to stand up and help this situation especially policy makers.

Why can’t you at Ambrose Academy for example extend these services to these children especially that I always hear parents particularly those with autistic children talk about the great improvements they notice in the children once they start at school?

Well we have always asked to be subsidised and the answer we get is that it’s not in the government policy. However NORMAL developing children can be sponsored in private institutions and that’s OKAY BUT FOR CHILDREN WITH SPECIAL NEEDS WE would rather give them P300 MONTHLY. I mean if we don’t do anything now can we ever sponsor them in universities while they are not rehabilitated? No ways. I have asked government since it used to sponsor these children in South Africa, why can’t the sponsorship be extended to services like ours? All the international visitors are saying why government is not assisting your efforts? Who is government Rachel? It’s the people working in government. What they do is to find 100 reasons why they can’t sponsor children in our school even though they can see with their own eyes how we have improved the lives of these children.

The only thing to do I guess is to continue advocating for all these children until Policy Makers hear us, and realise that only talking about how we want to improve special needs children lives it will NEVER happen unless we make it possible for them through enabling policies and implementation not just talk.

Share some of outstanding moments of your time in the US
One of the aha!moments I had was during an assignment I had to write my obituary and read it to the audience. It was so intense and very emotional to a point where Prof John kept saying remember guys you are not dead but we couldn’t help crying because it included how you have empowered your family and how your people will remember you by the sacrifice you made for your country. Did you assist your patients and the children in Ambrose Academy simply because it’s the right thing to do or you sabotaged people you were serving? One thing I really wish for my country is for us to create opportunities for others, I normally say if you go to most organisations for assistance the norm in Botswana is that they will tell you 100 things why it can’t work instead of 100 ways to make it work. However in USA they are willing to solve problems for the benefit of others. Imagine if we had that attitude in Botswana.

The whole experience was eye opening and I will like to encourage all young people to apply for it so that they can go and learn from those who are ahead of us. We need to see the possibilities so that our dream for our country becomes even more brighter and we can indeed tell our African stories instead of others telling them for us.

Is there anything we can learn from the healthcare system of the US?
Health is expensive! I think this is the first step we need to appreciate in Botswana, running away from this breaks my heart. Investing in experts, resources and research is costly; do we have health research units? That’s the only way we can improve our health system. We do not need to re-invent the wheel it’s already invented by those who are ahead of us. All we need to do is work towards that. Nowadays when people are hospitalised I hear them saying I know I am going to die, hospitals should save lives not become places of NO HOPE. We need to change that.

What does the future hold for you personally and Ambrose Academy?

The future is exciting MWF2018 has increased my network where I can learn from others and continue to improve myself. I was kind of losing hope with all the efforts that I have tried but now I have been ignited. As Ambrose Academy we will continue to raise the bar and ensure we remain relevant to bring value to Ambrose Academy children, even all other children in this country. We will soldier on and leave no stone unturned until our voice is heard…… GIVE CHILDREN WITH SPECIAL NEEDS AN OPPORTUNITY THEY ALSO DESERVE TO HAVE A BRIGHT FUTURE THEY ARE NOT DOOMED …..

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Diatician Makuku: Tells of what your body needs

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Growing up, Diatician, Keitumetse Makuku of Bonatla Wellness Solutions at AO Clinic was a fussy eater, she admits, she still is.
She recalls her late grandmother carrying a stick at every meal time. Today, she has has made it her life’s mission to educate people on good nutrition.

What made you choose this career path?
Growing up I would line up my mom’s deodorants, colognes and body lotions as my students. I knew that I wanted to teach people and educate them on how to improve their lives. Hence I chose Dietetics, which entails educating people on good nutrition and improves their lives.

What was your diet like growing up?
I was a fussy eater, my late grandmother would always be carrying a stick everytime I had to eat. I am still a fussy eater and don’t eat a lot of foods.

If you could persuade people to change three things about their diet, what would they be?
Eat foods that you enjoy so that you can be consistent with your healthy eating. For example, we know healthy eating entails eating mostly wholegrains, fruits and vegetables, low fat products, low fat dairy products and lean meats like chicken. From the wholegrains group make sure you eat that which you enjoy so that you can be consistent. There are individuals who love eating korong whereas others love eating mosutlhane or both, in this case I should not feel pressured to eat items I don’t like, including brown rice. Some people believe that healthy eating is when you eat fancy foods that entails shopping for expensive vegetables they can’t afford and only eat for a short period of time. Eventually, such people will tell you that they don’t enjoy the food but are just eating it because it’s considered healthy.
Keep it simple, our forefathers were healthy on their traditional foods. Lifestyle modification is a process and it begins with you as the individual. If you want to lose weight do it because you are ready and know and believe that it is the right thing to do, than doing it to impress your peers.

Are there any books, magazines, newsletters, podcasts or websites you would recommend for those who want to become better educated about diet and nutrition?
If you want to know more about good nutrition first and foremost there are professionals in the field, Nutritionists and Dietitians in all the different government hospitals and some are in private practices. They are the right people to give nutrition advise and guide. However, if you want to read about any nutrition facts you need to search peer reviewed articles which have different research findings about nutrition issues. Look for the latest journals as Nutrition is dynamic.

What are some of the most common nutritional mistakes you observe in your clients?
The most common nutritional mistakes I observe made by individuals are that they believe that starchy foods contribute to weight gain. They also believe that starving oneself or skipping meals is helpful in weight loss. They also restrict the intake of important nutrients that can be beneficial to health.

What is a typical day’s breakfast, lunch, and dinner for you?
Breakfast is the most important meal of the day. One cup of oats with a fruit is my favourite, then take in water afterwards. Lunch – one cup of samp and beans with one cup cooked morogo and a piece of lean beef with a bit of gravy and a fruit. Dinner for me could be baked potatoes with one cup of green salad and chicken. I enjoy simple healthy dishes.

There is a lot of hype around intermittent fasting (IF) lately. What are your thoughts about fasting as a dietary technique?
Bear in mind that the amount of food that one eats is dependent on a lot of factors such as physical activity, weight, and basal metabolic rate. Fasting varies according to different religions. Some omit all the food items and use water only, while others omit other food items and remain with a few food items. Therefore, what I can say is that provided you do not have any medical condition you can go through any kind of fasting for religious purposes, however, when you want to lose weight you cannot use fasting because for the body to lose weight it requires to be satisfied first, then that is when it can start shedding off the fat. I do not despute that fasting generally makes one lose weight, but when you want to maintain that weight loss it becomes difficult because your body will start to experience cravings which you would want to curb by overeating.

We are constantly told how ‘bad ’meat is and encouraged to have meatless meals. What’s your take on vegetarianism and veganism?
Meat is not bad, too much high fat meat is high in calories and saturated fat which contributes to weight gain and increases the chances of heart diseases. However, if you eat lean cuts of meat, chicken and fish you also benefit from the nutrients such as iron from red meat, protein, omega 3 and 6 fatty acids from fish. There are however, individuals who opt for vegetarianism for personal, religious reasons. They also benefit from plant proteins which are low in cholesterol, also contain protein. As long as one substitutes the right nutrients then it is acceptable.

What is detoxification and how do you feel about the need for it?
Detoxification as the name implies means getting rid of toxins in the body. What are toxins? High fat foods, high sugary foods, high refined foods, high salty foods. All these become toxins but when you eat healthy i.e wholegrains, low fat products, low fat dairy products, lean cuts of meat, more fruits and vegetables you do not have to detoxify. Eat healthy and avoid having to use the word detoxification.

What kinds of tools and methods do you use to help your clients achieve their goals?
As a Dietitian we are trained to educate, advise and counsel individuals on the right way of eating. We do not impose it to them but we make suggestions. We also give you the risks to unhealthy eating, and allow you to think about what healthy eating can benefit you and your family. We work together with individuals to reach a desired healthy goal.

How important is exercise and how much of it is effective?
Physical activity and not exercise is very important as it promotes good health. Relieves from stress, gives more energy, helps in shedding off fat. However, I always advise that people do what they enjoy most and not exercise because their friend is doing it. You can jog, brisk walk, swim, or anything that you would enjoy so that you can be consistent.

Any words of advice or suggestions for someone considering entering your field?
If you want to study Nutrition and Dietetics you need to have a passion for it.

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