The pills came from somewhere

Last summer in Gaborone, I spent several days unable to do much of anything. E. coli, plus a viral infection I didn’t know I had until a blood panel came back. I was in a private hospital. The staff were excellent: calm, well-trained, unhurried in a way that surprised me until I remembered that the unhurriedness was part of what I was paying for. I left with multiple prescriptions and a bill my insurance handled.

I want to be honest about that. The care I received is not the care most people in Botswana receive, and I was a foreigner in a private system that exists in part because foreigners and a small domestic elite need somewhere to go. I don’t want to make my hospitalization stand in for anything it can’t stand in for. It was one night of one patient, and the patient was me.

But the prescriptions came from somewhere.

A friend I worked with there told me, almost in passing, that Botswana imports all of its medicines. The only pharmaceuticals manufactured domestically, he said, are veterinary: drugs for cattle. I laughed when he said it, because of how the sentence lands, and then I stopped laughing, because of what it means.

Every pill in every clinic and every hospital in the country has crossed a border to get there. The Central Medical Stores in Gaborone is the body that makes most of that happen, procuring, warehousing, and distributing medicines for the public system across the country. It is, in a real sense, the spine of Batswana healthcare. And what it spends most of its energy on is not deciding what to prescribe or how to treat; it’s getting the things into the country in the first place, and then getting them to the right place at the right time before they expire.

This is the kind of constraint that doesn’t show up in most conversations about health systems. We talk about doctors per capita, or insurance coverage, or disease burden. We don’t usually talk about lead times, or single-source suppliers, or what happens when a regional manufacturer changes a formulation, or what a stockout in Francistown looks like when the next shipment is six weeks out. But these are the questions that actually shape what care is possible on a given Tuesday.

The pills I took in Gaborone came from somewhere, probably India, possibly South Africa, possibly farther. They reached me through a private pharmacy that runs on a different supply chain than the public one, but the underlying geography is the same. A country of two and a half million people, no domestic pharmaceutical industry, surrounded mostly by one much larger neighbor, has to build its health system as a logistics problem first and a clinical one second. The clinical part is the part that gets photographed. The logistics part is the part that determines whether the clinical part is possible at all.

I’d seen something like this before, though I didn’t recognize it at the time.

A few months earlier, with classmates from the Global Health Program, I’d been on a boat on the Amazon outside Macapá. In the harbor were the ambulance boats, ambulâncias fluviais, river ambulances, tied up between runs. They carry supplies and emergency care upriver to villages that aren’t reachable any other way. I didn’t board one. I didn’t talk to the crews. I was a student passing through, and I want to be careful about what I claim to have learned from a thing I mostly just saw.

But the image came back to me later, in Gaborone, because of how obvious the adaptation was once I knew to look for it. A health system in the Amazon basin has to be a fleet, because the roads are rivers. A health system in a landlocked country with no pharmaceutical manufacturing has to be a logistics operation, because the medicine starts hundreds of miles from the patient. The shape of the system is the shape of the constraint.

This is not a profound observation. I think what surprised me is how rarely it’s the first thing said about a health system. We talk about systems in terms of outcomes, or spending, or coverage, all real things. But underneath those is a more boring question: what does this place have to move, and how far, and through what? The answers aren’t policy. They’re geography and trade and history. The policy comes after.

I don’t have a tidy thought to end on. I’ve spent the last year working on a piece of one of these systems, and the more I work on it the less I trust the instinct to compare across them. The boats in Macapá aren’t a lesson for Gaborone. The Central Medical Stores isn’t a lesson for the Amazon. They’re answers to different questions, and the questions are mostly being asked by the land.