How do you measure the short-term return on investment of saving a child’s life?: an interview with Unami Mulale

August 18, 2016

Unami Mulale is a Pediatric Global Health Fellow at Boston Children’s Hospital from Botswana.


What is your current position?

I am currently a Pediatric Global Health Fellow at Boston Children’s Hospital.

Can you tell us about your career path?

I am from Botswana, born and raised. I grew up there and decided to become a doctor after a year of national service in Botswana, but there were no medical schools in Botswana at the time, so I went to medical school in Grenada, and transitioned to the U.S. for residency and fellowship. I am a pediatric critical care specialist. I trained in New York at Long Island Jewish Hospital, then I worked for four years in Brooklyn, in an underserved area at Woodhull Hospital. Now I am a Pediatric Global Health Fellow at Boston Children’s. 

When I am finished with GHDI, I will return to Botswana and start work as a lecturer at the University of Botswana School of Medicine. As far as I know, I’m the only pediatric critical care specialist from Botswana. The university will be opening a new university teaching hospital, which has some allocated pediatric ICU beds. So essentially I’m going back to help develop the pediatric ICU and help run it and teach.

Can you share your top career goal?

I don't think of my life in terms of “career goals.” I would say though that I guess the most important thing I would like to see actualized is tertiary healthcare in Botswana—pediatric tertiary healthcare. I think that my work stems from a deep belief that every life matters. I really, really believe this. And I think that if every life matters then every disease matters, and if every disease matters, then every death matters. I think that we tend to address different diseases with different intensity, and we tend to put resources toward what we think matters or toward what gives us greatest outputs or returns on investments.

For example, in Botswana, diarrhea and pneumonia kill 36% of children. HIV/AIDS kills around 10% or less. But the resource allocation to HIV/AIDS is astronomical compared to the actual killers, diarrhea and pneumonia. And that bothers me. I really think healthcare shouldn’t be about what is of greatest interest to us or what we can get out of our work or research, it should be about how to best cater to the needs of our patients. Placing a tag on the lives of our patients bothers me a lot. When we’re talking about return on investment and cost effectiveness in reference to lives, it bothers me. 

My greatest desire would be for everyone to be viewed as equally important and for tertiary healthcare to be built alongside the primary healthcare that already exists in Botswana.

What is the biggest challenge you face in meeting your goal?

The biggest challenge I think is health equity: who matters and why do they matter? In Botswana, everyone strives to be old because the old are respected and revered. And systems reflect that, we don’t have a pediatric ICU, we don’t have specialized pediatric critical care services. We give value to certain groups of people over others. Short term, a child’s life you save is not going to contribute to society, to GDP. How do you measure the short-term return on investment of saving a child’s life? How do I make every life matter? How do you make people believe that every life matters and that it’s actually worth it? I think people talk about critical care based on returns on investment, but we look to the money because we don’t actually believe that those lives are worth saving. To say that critical care wouldn’t work in the non-western world is flawed.

What impact do you think GHDI will have on your career?

For me, what’s been important is the relationships I’ve formed. You can’t bring about meaningful impact without others. “If you want to go quickly, go alone; if you want to go far, go together.” That’s an African proverb. I think that the relationships have been the most important, just knowing people you can bounce ideas off of and collaborate with.

What do you find most satisfying about your work?

Regardless of the outcome, I want families to know that somebody cared, someone tried, in one of the darkest times of their lives. A family knowing that someone was there and that someone tried, that’s it, that’s important. I think too often in the non-western world we give up because we’ve been told, “You can’t do critical care here.” So we just watch children die because somebody said, “You can’t have a pediatric ICU in Botswana,” which is horrible. Who decided that? 

What advice would you give to someone just starting out in health care in your country?

Don’t do it if you’re not sure you want to do it. Medicine consumes your life. You’re living in the suffering of others, and you’re not an invited guest. You enter into the suffering of others uninvited but essential to their journey, and if you’re not sure you want to be in the space, you shouldn’t be in that space, because it’s a sacred space. When people are sick, it’s a very vulnerable and tender time, and it’s an honor to be in that space with families.