BU Collaboration with Lesotho Reaches Critical Milestone
In October 2023, a ribbon-cutting ceremony held in Leribe, Lesotho, a small mountainous country in southern Africa, marked the completion of construction of the country’s first post-graduate medical training facility. It was a collaborative project, part of an ongoing partnership with the Chobanian & Avedisian School of Medicine and the Lesotho Ministry of Health (MOH), known as the Lesotho Boston Health Alliance (LeBoHA).
As reflected in the remarks of Lesotho Minister of Health Selibe Mochoboroane, Deputy Prime Minister Nthomeng Majara and U.S. Ambassador Maria Brewer, the ceremony was also an opportunity to recognize over 20 years of work by Boston University and the government of Lesotho. That partnership resulted in nearly 200 new doctors returning to their native country to practice medicine and receive internships and specialty training and the country’s first medical school now a government priority.
“This is not just a physical structure, but a symbol of our shared commitment to the health and well-being of the people of Lesotho,” Ambassador Brewer said at the ribbon-cutting ceremony.
Recognizing its achievements in strengthening Lesotho’s health system, the United Nations Interagency Task Force/World Health Organization 2022 Special Programme on Primary Health Care Award was presented to LeBoHA before the UN General Assembly.
Boston University has a long history of international involvement and service with over 300 teaching, research and service activities on all seven continents, and a diverse student body of nearly 12,000 international students representing over 145 countries. BU had a health program in West Africa in the 1970s and worked with Egypt through the 1980s to develop a medical school and family medicine residency training program. The schools of medicine and public health conduct service delivery, operations and policy research programs world-wide.
BU has been involved with Lesotho since 1990, particularly through the work of the late William Bicknell, MD, founder and chair emeritus of the BU School of Public Health Department of Global Health and professor and director of international health programs in the department of family medicine at the medical school, and Brian Jack, MD, professor and former chair of family medicine.
The collaboration started decades ago as a collegial conversation between Bicknell and Jack. Bicknell, who passed away in 2012, had traveled to 62 countries over a five-decade career furthering public health, and Jack recalled that the two were discussing a hard reality that the international projects both had undertaken during their careers often didn’t last beyond the few years they were supported by grants.
“It’s not even a net neutral; it’s often a negative, because nothing sticks,” Jack remembered Bicknell saying. The two men talked about a different approach: getting to know a country first, talking to the people, the government officials, and then carrying out the work the locals had identified as priorities that would be sustainable long term.
Bicknell and other BU faculty had long-standing relationships in the country and Lesotho certainly needed the help. After South Africa ended the use of foreign workers in their mines, 300,000 Lesotho men returned to a country dominated by subsistence farming as its main source of income. The country was poor with nearly half the population earning below the poverty line. Its tuberculosis infection rate was the second highest in the world, the maternal death rate per live births was the second highest in the region and nearly 20 times that in the U.S. But it was the HIV/AIDS epidemic – with nearly a quarter of the population infected, and national life expectancy reduced to 36 years – that really threatened the country’s future.
This was a country desperately in need of physicians. The World Health Organization estimates that 2.5 medical staff, including physicians, nurses, and midwives per 1,000 people are the minimum needed for adequate health care. But in the early 2000s Lesotho’s ratio of doctors-to-patients was a meager one physician per 20,000 people, only one-third that of the African continent’s national average.
At the root of the problem was a brain drain – the government paid for 10 to 20 of their brightest students to go abroad each year, usually to neighboring South Africa, to attend medical school. But few of those students returned to their home country. Those who did were generally assigned to remote mountainous areas where they encountered a wide range of medical issues for which they weren’t prepared, with little or no support system, poor pay and living conditions, and lack of opportunities for teaching, research and career growth.
As a result, said LeBoHA Executive Director Elizabeth Nkholongo, many of her country’s doctors came from the Democratic Republic of the Congo or Cuba, and couldn’t speak English or, more importantly, Sosotho, the primary language of the Basotho people.
“It was just challenging for us because the local people could not easily access health care services because they could not communicate with the doctors,” she said.
Lesotho did have a stable transparent democracy and a healthcare infrastructure with a national hospital, district hospitals and health centers. And there was a core group of idealistic Basotho physicians who expressed interest in returning to take care of their country, their villages, their elders and communities and address the healthcare crisis.
In 2002, the Lesotho Minister of Health and Social Welfare indicated the government was interested in working with BU. In 2003, then-BU President John Silber agreed to a long-term institutional commitment to the country.
Over the past two decades, LeBoHA, supported by other funders like the Dreyfus Health Foundation and the W.K. Kellogg Foundation, worked with the government to stop the exodus of young doctors, and to build up both in-country training, facilities and support. They formed a medical students association in 2007; initiated Lesotho’s first physician training program in 2008 as a four-year post-graduate specialty-training program in family medicine; and created the first competency-based nursing and midwifery in-service training program in 2009.
In 2015, the physician training program was the first in the country’s history to gain accreditation. By 2019 the Ministry of Health was requiring all students finishing medical school abroad to return home for internship training. Due to their success with their Family Medicine Specialty Training Program, LeBoHA was tasked to run the internship program as well.
BU supports the education of those who commit to stay in Lesotho with a $1.5 million endowment from former BU School of Public Health Professor, the late Rex Fendall and his wife Doreen, who left their estate to be used to support health workers from lower middle income countries who are committed to returning to their native countries to further their education.
Lesotho physicians who return and graduate from the family medicine program are still assigned to rural districts, but now they have a more robust support system, working together in teams. They hold management positions and participate in continuing education that includes regular professional meetings, training updates, teaching positions and opportunities to do research and publish articles. Their advanced training in the clinical conditions facing the country, and their training in improving the quality of care, community-oriented care and district health management give them with the skills and confidence to provide the services needed to work in the districts. With these skills, locally trained family medicine graduates now are in seven of the 10 districts in the country and, to date, none of those postgrads have left the country.
“The people who are actually leading the work on the ground in Lesotho are people who have been trained (in the LeBoHA program),” said Stephen Wilson, MD, MPH, FAAFP, chair of the Department of Family Medicine and chief of family medicine at Boston Medical Center (BMC). His department oversees the LeBoHA program.
With funding from the United States Agency for International Development Schools and Hospitals Abroad program, LeBoHA supported the construction of the Postgraduate Medical Campus that now includes an academic center, library, administration building and dorms. One of the buildings, the Bill Bicknell Academic Center, was built with funds raised by LeBoHA and the nonprofit Global Primary Care.
Jack said the success of LeBoHA’s family medicine post-graduate program offered proof that other medical education programs could sustain themself beyond grant funding. The government now pays the salaries of the returning doctors, the faculty and the cost of the training programs. Jack, and Minister of Health Mochoboroane, said the country has prioritized building its first medical school, possibly within the next five years.
“We have addressed the brain drain issues to encourage people to come back home,” said Jack. To date, 24 specialists and 170 interns have returned from abroad for post-graduate training and 90% of those have stayed.
“Our claim to fame now is that there are more doctors in the LeBoHA training programs than there were in the country in 2005,” said Jack.
As it so often does, success breeds success.
“Because this program has been successful at producing good physicians, the government is asking us to help them model specialty training in other areas,” said Wilson, who traveled to Lesotho for the first time this year and attended the ribbon cutting ceremony.
“I would say that’s a significant marker of sustainability, when you start to build on, and add programs on to what you’re already doing,” he said.
Over the past decades, BU faculty and students and BMC physicians and residents have come to Lesotho to help.
The LeBoHA program attracted Stephen Christiansen, MD, chair of the Department of Ophthalmology and professor of ophthalmology and Pediatrics at the school and chief of ophthalmology at BMC, who had been trying, and failing, for years to find a site in Rwanda, Zimbabwe or another western African country to establish an eye clinic and surgery suite.
What he found in Lesotho was a mature program that had government support. He also uncovered tremendous need – with just one ophthalmologist in a country where cataract blindness afflicted 30,000 new patients each year.
“Consider the enormous burden it is to have a substantial part of your population blind as a consequence of a preventable blindness,” said Christiansen. His program started an initiative to train district nurses to do both eye exams and surgery. “To be able to train a nurse and to put them in a district hospital with equipment and support would be really terrific and a substantial way of improving cataract blindness.”
While the nurses get most of their training in a two-year program in Gambia, specialists from BU and BMC treat patients in Lesotho, but also train nurses. The experience was also important for the residents and trainees from BU.
“As a chair, I want to open my residents and trainees’ eyes to what the needs are in the developing world, to how people can be helped with even modest interventions,” he said.
David Henderson, MD, psychiatrist-in-chief at BMC and professor and chair of the Department of Psychiatry has worked in many resource-limited countries, evaluating mental health needs and setting up training. When he came to Lesotho a few years ago, there were no psychiatrists and his department sponsored a PhD-level fellow for the past two years to lay the groundwork for a training program.
Participating in the programs overseas makes residents and trainees into better physicians, he said.
“You have to figure out how to be useful, how you treat this illness without an MRI or fancy tests. How do you treat it with the tools that you have,” said Henderson.
Jag Bhawan, MBBS, professor of dermatology, was at the Lesotho medical campus in October working on solutions to a critical shortage of dermatologists and pathologists and said he was impressed at the energy and commitment of the Basotho (the name for the people of Lesotho) physicians and medical staff he met there.
“They are all local people who have graduated from the program, and they are now on the faculty, and they are absolutely committed to improving health care there,” said Bhawan. “I met so many people who are really trying very, very hard.”
Of the nearly 20-year effort to build a health care system in Lesotho, Wilson said operating at the pace set by the people and government of Lesotho has paid off.
“By doing that, and having buy-in along the way, it’s cemented into the culture,” he said. He said that buy-in was evident in how Lesotho government officials and the communities interacted with Jack.
“They were thanking him, not in a way that showed he was the boss, but in a way where they looked at him as a collaborative partner,” said Wilson.