The ride from Gaborone to the hospital in Molepolole starts in the dark. By the time the sun rises, we are onto Donkey Road, a 40km drag that lives up to its name of scattered donkeys, pensively exploring the highway at their peril. The story goes that there was a carriage that served as a taxi to animals: a cow, donkey, and goat. When the cow got off at his stop, he paid his fare. The goat skipped the bill and bolted. You can find the cow pleasantly grazing by the road; the goat running away; and the donkey still waiting for his change in the middle of the road.

We are three doctors’ driving to a rural hospital with a mix-tape of 90’s emo music, a few stethoscopes, and bagged lunches. The day unfolds like a sandwich, a morning of pensiveness while driving between the rising sun and full-setting moon, a 12 hour day of caring for patients, and an evening of repeat pensiveness, often driving through dark, honking at donkey’s.

Scottish Livingston Hospital (SLH) sits on a small perch in Molelopole, surrounded by small merchants selling candy and gum on the dirty road leading to what appears to be a corporate megaplex of a hospital. The old grounds lurk behind the glass-reflecting exterior, salmon-colored tinned roof structures with courtyards, trees, and life-size replicas of zebras. We will eat lunch on the stoop of the courtyard next to broken windows, warming M&M’s in the sunlight. The inside of SLH looks unlike a typical American hospital – patients are partitioned into “cubicles” of six, with sliding curtains serving as separation for privacy. It’s nearly two weeks in and I still ask about what “bed” my patient is on, only to be met with blank stares.

My co-resident and I manage the female ward of thirty patients while the attending physician works the mornings on the TB ward. As western-trained physicians, we find ourselves often helpless on the basics — how to draw blood from a hypovolemic patient, how to properly hang IV fluids, and which of six numbers to call for pharmacy help. If the system is inefficient, we arrive as good company. The allure of “real medicine” drives many residents across the globe here – I was told so much in my first week, that many seek out this rotation to “do lots of procedures.” Another US trainee told me that I would see “some great pathology.”

On the female medical ward, one nurse cares for a separate cubicle, rounding on each patient and in meticulous cursive documenting the subtleties between “ill-appearing” and “grave-appearing.” One day a patient appears cachectic, another day emaciated, and a third day merely thin. As in the US, the zeal to document often outstrips commonsense — what kind of clinicians would we be if we needed to verify our patient as malnourished?

Everyday I walk past my patient in bed 1, a 28 year old with HIV and unexplained anemia, hoping to see that the lab processed her blood in time to get her a transfusion. I am a source of efficiency, pain, and amusement to her: efficiency, as I likely expedite her transfusion by a few hours, pain as my phlebotomy skills leave undue tracks in her arm, and amusement as I can’t seem to use a tourniquet properly.

If the first moral conflict regards my own net benefit, the second is of basic utilitarianism. As a patient crashes at 9am during the start of rounds, we have to make a choice of how far to go in treating her. In the words of our attending physician, “You have to make a utilitarian decision – instead of spending you time with the patient in respiratory failure with a poor prognosis, your time may be better spent preventing a half dozen patients from getting that sick.” In an environment set up for “real medicine,” moral conflict has a way of obtrusively rearing its head.

The third moral conflict is the most taboo – our relationship with the health center practitioners. To call the staff local would be a misnomer – physicians and nurses come from as far as Congo, India, Ghana and Cuba to practice medicine, largely due to the larger salaries afforded by the Botswanan Ministry of Health. The conflict is moral in the sense that I cannot do for my patient what I can in the US – though this is not particularly surprising. The conflict amplifies when it brings me into interaction with the people behind a struggling system. To wait hours for blood for a patient in need of transfusion would feel borderline criminal in the US, though is routine because of time-lags in the computing system, and delays of communication. This is but one of hundreds of analogous issues – from warming patients with extra linens in the operating room to providing comprehensive follow-up for patients on anticoagulation meds. These issues will not be solved in tense conversation on the phone with pharmacists or in bureaucratic morning staff meetings. This is the shadow of the “real medicine” many seek to find. To step into the shadows is uncomfortable as it begs the question: who am I to demand efficiency in a system where I am not personally committed for the long haul?