It Takes 30 Villages: Building Trust in a Clinical Trial

People attending Kgotla, the public village meeting

Because of his own history, Dr. Mompati Mmalane had ideas about how best to introduce a complex clinical trial to communities like Shakawe, a remote village in northwestern Botswana.

HIV is no stranger to rural villages. Although the national adult prevalence is 24%, the rate is much higher in some villages. Older adults remember the days before antiretroviral treatment (ART), when Saturdays were crowded with funerals for friends, relatives, and neighbors who had died of AIDS.

The Botswana Combination Prevention Project (BCPP), a trial designed to reduce HIV incidence at a community level, takes place in 30 villages across the country. In theory, people should welcome improved HIV testing and treatment efforts as well as improvements to local clinics. Rural villages like Shakawe often lag behind urban areas in access to medical care.

In reality, services will only be utilized if a sense of trust is established between residents and the BCPP team. For the study to succeed, researchers had to first gain the community’s confidence. Without it, their clinical trial would fail.

As Co-Chair of the BCPP Community Engagement Working Group (CEWG), Mmalane was charged with explaining the study and encouraging people to participate. “When you want to do something with a community, you need to understand their culture,” he said. “Batswana are a consultative people. We like consulting. Some people say there’s too much consulting, but we like to consult.”

Dr. Mompati Mmalane
Dr. Mompati Mmalane. Photo by Dominic Chavez

“My team’s role is to get them to take part in the study,” he said. “That’s the main objective.” Participation in the trial is voluntary, he emphasized. Individuals are enrolled in the trial only after a strict informed-consent process is followed. Once a participant agrees to enroll, he or she may withdraw at any time.

The Unusual Life of Dr. Mmalane

Mompati Mmalane was born to a single mother in Semolale, a small village in eastern Botswana. “There was no doctor, no clinic, nothing,” was how he described it. His grandfather named him Mompati, meaning my partner, and taught him how to farm and tend cattle.

When riding on the back of his uncle’s bicycle, the young Mmalane’s foot got stuck in the spokes of the back wheel. The wound became infected. His grandfather took him by bicycle to the big village of Bobonong, about 30 miles away. There weren’t any roads, just tracks over the hills, so the trip took a whole day. At the clinic, the health worker applied ointment to Mmalane’s wound and gave him antibiotics. His grandfather pedaled him home the following day.

When his grandfather died a few years later, Mmalane stayed in school. It wasn’t the obvious choice for a boy who was now the man of the family. Many of his classmates left after fourth grade to work on potato or cotton farms. “At that time, most Semolale parents felt that if you could read and write your name, you were educated,” remembered Mmalane. His mother had little schooling herself and by then had five children, but she encouraged her oldest son to continue in school.

He excelled and earned a scholarship to university. He hoped to become a doctor. After two years at a local university, he would be sent to a foreign medical school, ideally in Canada, Britain, or New Zealand. But when a sponsored spot opened up in Germany, he took it, though he didn’t speak a word of German. He boarded a plane for the first time and left Botswana.

Young Mompati Mmalane (dark jacket) says goodbye to friends at Gaborone Airport.
Young Mompati Mmalane (dark jacket) says goodbye to friends at Gaborone Airport.

The expectation was that Mmalane would study German for a year to pass the medical school entrance exams. After just six months, he felt ready. He took the exams, passed, and was accepted at the University of Tübingen. He was the only African in his class.

“Initially, life was a bit of a challenge,” he said. Someone gave him an old bicycle. One day he rode it on the Autobahn. Cars passed him honking loudly. He thought, “Oh, well, they must be racist.” When he mentioned the incident at school, a teacher said, “You never go on the Autobahn with a bicycle! Not even a moped!” Mmalane smiled when recounting the incident.

He thrived, made friends, studied hard, and graduated with his MD in 1986. He describes his years in Germany as the best experience of his life. “Being accommodating of other people’s culture was very important.”

He returned to Botswana to work at Princess Marina Hospital, where he stayed for nearly two decades, leaving once to train in surgery at the Royal College of Surgeons in Edinburgh and later to train in orthopedics at University College London. He married a nurse. Together they had four children.

In 2005, Mmalane was asked by the Ministry of Health to become Botswana’s first Director of Clinical Services. He stayed until 2008. In 2009, he joined the Botswana Harvard Partnership (BHP).

Lasting Relationships

The CEWG returns to a village about a month before the BCPP field team arrives. The purpose of the visit is to bring the leadership up to date about the study and inform the community about what to expect in the coming weeks. Because Botswana has a number of different ethnicities, each with its own customs and code of conduct, every meeting is different. In these situations, Mmalane, a villager himself with knowledge about how to negotiate different cultures, works hard to unite local concerns with the requirements of a rigorous clinical trial.

Photo by Dominic Chavez
Photo by Dominic Chavez

Meetings are held with the village leaders first. Especially important is the meeting with the Kgosi—the chief. Others consulted are the Village Development Committee (VDC), political and church leaders, community-based organizations, and traditional healers. “You really need to work with these guys right from the get-go so they’ll assist you in answering questions from the community,” said Mmalane. “The community should see that the leaders are already on board.”

After speaking with the leadership, Mmalane requests permission to address the Kgotla, the public village meeting (much like a town hall forum) where community decisions are arrived at by consensus.

At the Kgotla, Mmalane talks to the people, explaining how the study, called Ya Tsie in Setswana, will help determine the best methods to prevent new HIV infections. He explains that the field team will begin door-to-door HIV testing and the steps that will follow. He asks villagers to consider providing accommodation for the 30 members of the team. “If we segregate ourselves, we will always be looked at as those people from Gaborone. It helps us recruit if people feel that we are part and parcel of them,” he said.

Questions from the community are encouraged. If the CEWG has done its job well, the Kgosi and village leaders provide many of the answers. Mmalane stays as long as necessary, patiently talking with anyone who has a concern. “He’s got a medical background, so people ask him all sorts of things related to their health,” said Ernest Moseki, a member of the CEWG. “At the end of the meeting, they feel like this man has responded to their questions over and above the fact that he came there to sell them the study.”

“Dr. Mmalane is a humble man,” said Kutlo Manyake, a BCPP field team supervisor. “He takes time to get to understand what people want. He always brings their interest before his own. In the Setswana culture, a humble man is a respected man.”

At the end of the campaign in each village, there’s a farewell meeting that Mmalane often attends. Team members thank the villagers for accepting them, for providing accommodation, and for giving them their time and trust. The villagers discuss how they view the clinical trial and the team’s conduct. There are heartfelt remarks, some criticism, and often laughter between the team and the people who have hosted them.

Leaving on good terms is important. The relationships must be honest enough to last. The team will be back again next year, and the year after, and the year after that for the final visit.

Title photo by Dominic Chavez


martha_henry


Martha Henry is the Director of Communications for the Harvard T.H. Chan School of Public Health AIDS Initiative.