WONDER WOMEN 07. unami mulale
My name is Unami Mulale. I grew up in Botswana as one of six children and was raised by a mother who didn’t complete elementary school and a father who went against tradition to educate his girls. I went to medical school in Grenada, and I subsequently did my pediatric residency and pediatric critical care fellowship in New York. I have a longstanding vision to contribute to building Botswana’s first children’s hospital. I am also a writer and poet, and I have an honorary MFA degree from the School of Visual Arts in New York City thanks to my ever-so-lovely best friend Leah Guerrero.
What led you to a career in pediatric health care?
My father, who grew up in abject poverty, had always wanted to be a doctor. After losing his dad in adolescence, he had no means of going to school and never realized that dream. Although his constant encouragement molded me, I had to choose the field for myself. After completing high school, I worked in a village clinic for a year as part of the Botswana government’s National Service program. This was perhaps the most solidifying experience towards my medical future. I discovered I had a very genuine love for fellow humans and an immense desire and capacity to alleviate their pain. In fact, healing became one of the things I wanted to define my life.
Children, especially, have always enriched my life. As the oldest girl in the family, I have always been tasked with caring for my siblings. Pediatrics was therefore the only natural path I could take within the profession of medicine. It was the right choice.
Why is health care and particularly pediatrics so important to you?
The availability and ease of access to health care affects every person’s life. I grew up with a maternal grandmother who was a paraplegic with no access to a wheelchair or any other health amenities. My father had a stroke 13 years ago and my mother died of cancer six years ago. I cannot separate my experiences from how I view my role in the delivery of health care. Appropriate and timely medical care should not only be a stated human right, it should be a delivered-on one.
Children are among the most vulnerable groups in every society. My life has always been surrounded with and impacted by children. Growing up, I would hear of my siblings who died before I could remember them. My oldest sister was stillborn due to umbilical cord prolapse. My brother convulsed to death in my mother’s arms when he was only a couple of months old while she had taken him to the clinic for a febrile illness.
Pediatrics is the discipline of healing children. At times, I feel as though the discipline chose me even before I chose it. Losing two siblings makes healing children a personal quest and redemption for me. Beyond that, I hope to make a positive print in life seeking medical justice for the underserved and underprivileged.
What, specifically, does your job entail?
I am a pediatric critical care specialist, or pediatric intensivist. This means I treat the sickest children in the hospital—critically ill children who are near death. I am often the bridge back to life or I help children transition to their next life. Every life saved is as important as every life we cannot save. Each life and death situation must be treated in a manner that gives the patient and their family dignity.
You are only pediatric critical care specialist in Botswana. What led you to bring this particular field of health care to your country?
Without critical care, children live and die by chance. Diseases that are no longer killers in the Western world remain major killers in low- and middle-income countries (LMIC) because of the paucity of adequate treatment. For example, the number-one killers of children in Botswana remain diarrhea and pneumonia.
I believe that every life matters. If every life matters, then every threat to life matters, no matter where and to who that threat is. The life of a child in New York is of the exact value of the life of a child in Botswana, and so access to health care must reflect that equality. Bringing pediatric critical care to Botswana is about health equity, equality, and the intrinsic worth of every child and human being.
I could not bear the idea that I have a skill that is inaccessible to my own nieces and nephews and little cousins in the country that raised me. I wanted to, and had to, come back to a calling that has always resided in me.
Can you talk a bit about the inequality that has become so intrinsic to health care systems globally? What impact does this have, in your opinion, and how do you fight against it?
Inequity and inequality are not unique to health care. Most of the systems and resources necessary for a positive human experience are skewed towards being available to certain cadres of society. It is true of education, clean water, housing, travel, and much more. All around the world, the people with the least possessions or those viewed to be lesser-than in society have been offered subpar services and crumbs off the master’s table. Childhood mortality is greatly impacted by factors such as geography (where one is born), maternal education, and access to clean water, to state just a few factors.
The field of medicine has made remarkable strides over the years, and so often what was once thought of as unique and groundbreaking is now routine care in certain places in the world. Many of the medical advances are limited to the Western world, and medical care in LMIC remains basic and restricted mostly to preventative care. Because of this gross disparity and injustice in health care systems, lives that can be saved are lost every day. (Please note that even in the Western world, there is a great imbalance in access to medical care based on such things as socioeconomic status, race, education, etc.)
Preventative care will always be necessary, but unless we foster tertiary treatment systems, mortality rates will stagnate. Preventative care and treatment are two legs of a body that is well balanced.
Limitation of innovative tertiary (specialty) health provisions should be deemed unethical. The stratification of access to specialty care implies that not all lives matter; or at least that not all lives are equal in worth. Cost is often stated as the major impediment to delivering adequate health care services, especially specialty services such as critical care. The worth of life is often reduced to numbers measured as return on investments to be calculated for the profits of institutions such as governments, pharmaceutical companies, educational bodies, and medical technology companies. (Basically, the question is: Is it worth saving this life? And too often, the answer for people who have the means across disciplines to do so is no).
I have not set out to fight inequality and inequity, but to use medicine as a vehicle to emphasize and actualize the truth that every life matters. My defiance against systems that insist on and define medicine in LMIC as beneath Western practice and almost only prevention-based is my way of practically seeking justice for the patients I serve.
We must view “global health” not as a code for “rich” countries practicing medicine and doing research in “poorer” countries, but as a field that gives agency to every health care worker to transform medical practice for the better wherever they are. Solutions for the best medical care can and must be innovated from the inside instead of from outside bodies such as WHO, Western universities, and others.
When I first said I was going to train as an intensivist, the universal response was, “Why? There is no critical care in Botswana.” My response was consistently, “But who decided that there shouldn’t be critical care in Botswana?” I could not accept the sentence bestowed upon Botswana’s children stating they were not worthy of specialty care. On a personal note, I could not accept that my nieces, nephews, and cousins were relegated to a world of health care restriction based on geography, cost, and voluntary shortsightedness.
Equalizing tertiary health care services is an issue of critical importance and a matter of life and death, literally. It is my fight. I provide a service many do not think can be provided in my environment—and one, for that matter, that many do not deem necessary to be provided because they do not value the lives I am trying to save, and in certain instances do not think those lives are savable.
You work in critical care. You take care of the terminally ill. What are the greatest challenges and greatest rewards in your work?
I treat critically ill children, some of whom are terminally ill. Unlike in most Western countries, where most critical disease is from noncommunicable diseases and accidental deaths, the vast majority of critically ill children in Botswana and other LMIC are sick from preventable and curable causes. Botswana’s largest contributors of under-five mortality are pneumonia and diarrhea—both avertable and treatable. The number of unnecessary pediatric deaths each year that can be avoided through better treatment measures are immeasurable. (I must say childhood mortality has continued to drop due to excellent preventative measures such as vaccines and access to clean water. We must now continue to eliminate unnecessary deaths by improving our treatment strategies).
My greatest challenge is the injustice that comes with the price tag attached to every child’s life, and the views that shape who gets treated, when they get treated, and how they are treated. Medical apartheid is universal, but it’s acutely more damaging for the poor and those living in LMIC.
My greatest reward is knowing I am doing what I am created to do. I hate this work as much as I love it. No one can love a child’s death, and I experience that a lot….But I love providing a service that would have otherwise been unavailable to the children, and I am so grateful when they live. If I must face death over and over again to deliver life, then that is a price I am willing to pay.
I’ve heard you talk about personal and community faith and how it has guided you to make life decisions. How does your faith intersect with the work you do?
As a young girl, I grew up going to church. When I was 18, I made the personal decision to be an active follower of Jesus and His teachings. Jesus has been central to all my adult life’s decisions, wading with me through my deepest struggles, including struggles with mental health issues, and celebrating my biggest victories. My faith has always given me a sense of being, a sense of belonging, and a sense of purpose. Because of my faith, I feel interconnected with other humans, since we are all made in the same image from the same mold.
Above all, my faith has given me the love that I pour into my work and into my interactions with my fellow humanity. This love is the hope and strength needed to come back to the difficult spaces in a quest to heal.
How are you working to change the institution of global health from the inside?
My work is not aimed at changing the institution of global health but at saving children’s lives by providing pediatric critical care where it is too often thought impossible. I hope that my work will speak for itself and thereby challenge all caregivers to a standard of excellence and open availability of restricted services in LMIC.
You are also an educator teaching at the University of Botswana School of Medicine. What advice do you give to people who hope to have a future in global health?
Don’t choose global health. Choose people. Love them. Treat them justly. Make their lives better. Heal them wherever and whenever you can. Respect every human life that has been gifted to your path. No matter what field of medicine or where you end up physically, do your best work. As healers, we are handling the most precious of things: life.
What are some issues regarding global health that you are most interested in combating?
I think the term “global health” is problematic and discriminatory. We do not refer to medical practice in the Western world as global health—the term alone implies prejudice and injustice, being reserved for the practice of medicine in LMIC and poorer parts of the West. The health care field must be equalized as much as possible, which requires financial, political, and technological will that, in my opinion, does not yet exist.
I am interested in minimizing unnecessary childhood deaths and having my patients recover in the best possible condition to give them a fruitful life. I am interested in innovating health care solutions in LMIC, for LMIC, by LMIC.
Who is a woman of empowerment in your life? Someone who inspires you and leads you to continue to pave the way for accessible pediatric health care?
My mother remains my most favorite person I’ve met. The greatest honor of my life has been being her daughter. My mother was an easy lover of people, a great listener and forgiver, and generous to a fault. She was a restorer to dignity, a mender of life, and a healer in her own right. She served the poor, raised other people’s children in addition to her own, and gave until she had nothing left to give. My mother loved children, and her way of life will forever be a leading force in my life.
My mission is... to spread color and joy and medically heal children of the world ☺ One day at a time.