Bangkok, elephant hunting and a highlight of the year

May started off with a trip to Bangkok with several of my colleagues working on the TB project for the Lifeline Clinic. Our project is to increase TB diagnoses in the San community by going out to screen people in their own villages and settlements. In order to stop the worldwide TB epidemic, increasing diagnoses is an essential goal, as there are millions of people worldwide that have TB disease but have not been diagnosed. In the last few years TB has overtaken HIV as the infectious disease that kills the highest number of people worldwide each year, despite only receiving a fraction of the publicity or research funding.

The four-day meeting gave us detailed information on the monitoring and evaluation of the project (data analysis to make sure the project actually makes a positive difference to TB diagnoses), introduced us to the STOP TB team, and provided lectures on public health. I loved it there. The projects and the people running them were super interesting. One group was working with the transgender population in Karachi, Pakistan. This underground and discriminated against population is at high risk of TB and the project’s aim was to use links in the ‘Khawajasiras’ community to screen this population for TB. My favourite project was an ambitious one to use drones in Madagascar. The aim was to transport samples of sputum (the main test for diagnosing TB) to the hospital, then transport medication back to the remote villages if the test was positive. Due to the difficult, mountainous terrain it can often take many days for the sputum samples to reach the hospital laboratory from the remote villages and completing the 6-month long TB treatment remains highly problematic. It was awesome to be associated with innovative and ambitious projects that could really make a difference to the communities where they are based.

Our project poster in Bangkok

I was left with three main thoughts from the meeting in Bangkok. The first was that perhaps we were way out of our league. At the meeting, there were world famous professors (famous in the TB world anyway), organisations with over 20 000 employees, prestigious universities, and then our tiny rural clinic with six staff. Second, it was a strange feeling staying in the poshest hotel I’ve ever stayed in, discussing grass roots solutions to TB problems in some of the poorest and most disadvantaged communities in the world. Could the hundreds of thousands of US dollars the conference cost have been better spent on the projects on the ground? My opinion is that the meeting was worth the money. If it prevents even one project from failing then it has paid back the investment.

Third, I liked it so much that maybe this is something I’d be interested in doing more of in the future. At the start of this year in Namibia I was absolutely certain I wanted to be an oncologist. Half way through the year I was reasonably confident that I wanted the variety and flexibility of becoming a GP, and now I have more interest in international health and infectious diseases.

Children at a school we visited singing the school song for us

One of the things that I’m going to miss about living in the Kalahari is the animals. There aren’t many jobs where the list of wild animals that you’ve seen while working include: kudu, aardvark, warthogs, baboons, black mamba, puff adder and boomslang snakes, porcupines and chameleons. Add to that the giraffe, rhino and wildebeest we see while visiting the San workers on game farms and I’m pretty much a safari guide now. When visiting a remote farm a few months ago, my translator was chatting to the Herero farmer who casually dropped in the conversation that he had shot a leopard the previous week. Disaster for animal conservation, but in his mind it was simply another animal killing his cattle and destroying his livelihood.

Naankuse, the parent charity of the clinic, is obsessed with baboons. Me not so much.

In the middle of May our district had a rare visit from elephants that had travelled over from Botswana due to the good rains we had this year. My translator and I took a detour from our TB work to spend a couple of hours looking for them in the area they had last been seen. We stopped to ask a guy at the side of the road whether he had seen the elephants or knew which way they were heading. He said yes, jumped in the car with us and pointed us to drive west. After about 15km he said he thought they were here, took a few seconds looking around on the floor for tracks and then told us he couldn’t find the tracks. He then told us that this was where he wanted to go anyway so he would depart here and we should have a nice day. We sadly didn’t find the elusive elephants, but I admire the quick thinking of the opportunistic hitch hiker.

Anton (name changed), who struggles with mental health problems, gave me one of the highlights of the year at the end of May. At the initial assessment last month in Windhoek, it was almost impossible for the doctor to assess him as he was so disabled by his psychosis. At his one month review he was a changed person and I couldn’t stop smiling when he answered the question ‘Who was Namibia’s first president?’ with ‘Sam Nujoma’, the correct answer. I don’t know what the future holds for him but perhaps there is a small glimmer of hope. I certainly can’t take any credit for this as I truly was just a taxi driver for Anton to his appointments in Windhoek.

On one of my last weekends, I took the translators to the local tourist lodge. We had a nice lunch with the new doctors and Clare, who then sadly had to go back to Epukiro because of some volunteer co-ordination issues. The translators and I went on a short walking safari, set up our tents and then were sitting having a beer. At that moment one of my translator’s cousins walked around the corner. They hadn’t seen each other for years as they lived around 180km apart, and didn’t know that each other had found jobs. Some of the rest of the evening was spent entertaining the San staff at the lodge we were staying at.

The best translator crew in town

Sadly, the rump steak I bought for the translators to cook on the braai didn’t go down so well. They complained after they’d eaten it that it was ‘too soft’, ‘lacked bones’ and had ‘no flavour’ as I refused to massacre these amazing steaks with a boatload of braai spice like they wanted. I asked them what they liked best at the end of the weekend. Their favourite things were taking photos by the swimming pool for their social media profiles, and the chance meeting with their San extended family. Similarly to when I took my football team to Windhoek, it is often not the activity that I expect to be popular that they appreciate most.

To reach further away from the clinic, the TB project is starting overnight camping trips. I took the new doctors, Anna and Donal, to show them how I have done my previous camping trips in the furthest away areas. We screened about 30 people on the first day, with one or two people with symptoms that could be TB. Sadly, at this time of year the temperature drops to below zero at night. Often the San do not have enough blankets or warm clothes to sleep at night so they stay awake all night by the small fires they have and wait until morning. They then sleep from sunrise to late morning before collecting more firewood for the next night. It’s difficult to imagine how tough a life that is. We were staying that night in a tent, had two sleeping bags each and I still found it difficult to sleep because of the cold. When I slept on my back my nose became far too cold, so I tried to fully submerge myself in the sleeping bag. Unfortunately, I encountered my own beer breath reflecting back at me due to us sharing a couple of warm, African lagers with our hosts earlier in the evening. I’ll leave the cold camping conundrum to the new doctors as I certainly wasn’t in the best mood to continue the TB screening the next morning.

The clinic buildings under a beautiful sky

It feels strange that I’ll be back in the U.K. soon. I have the perfect relaxed return to England planned in order to contemplate life and how the year has affected me – a stag do in Benidorm. I think I am going to write once more in June about leaving Namibia and returning to England.

 

‘All of my stars have finished.’

When I receive texts from friends and acquaintances in the community, sometimes they’re amusing, and sometimes I have to work out what they mean. One of the football players from the neighbouring village texted me late in the evening once, saying ‘Sir, all of my stars have finished’. I wracked my brain for what he could mean and could only come up with the idea that he was unhappy with life and was considering suicide. I replied in a hurry asking him whether he was alright and what I could do. After several more confused texts it became obvious that he had been asking me to buy him new studs for his football boots as all of his studs (stars) had fallen out (finished). Phew. 

TB work at a remote farm with San workers

There is a patient, Anton (name changed) in our area with mental health problems. Life is tough for him. The community does look out for him to a certain extent but he will often have to sleep outside and scavenge food from the dustbins when the community has literally no shelter or food to spare. We are not sure of his complete backstory but he can read and write to a reasonable level in his second and third languages, which indicates a high level of education before he became unwell. San, his mother tongue, generally isn’t a written language. He occasionally has moments of insight into his condition and came to the clinic a few weeks ago looking forlorn, asking us for help so he ‘wouldn’t be crazy anymore’. We took him to Windhoek to see the psychiatrist soon after, having to drive the 9 hour round trip in a single day (it coincided with another urgent job we had in Windhoek midweek). 

We made a quick detour to buy some fabric that day and left Anton by the car. He’s at risk of wandering off but we asked him to stand next to the car, and the guard looking after the car to keep an eye on him. After a short time in the shop we arrived by the car again with him nowhere to be seen. I had a momentary panic until we found that he had climbed into the back canopy  of the 4×4, relaxed flat on his back on the mattress with his feet up,  and started smoking a cigarette. Also, recently we took one of the village chief’s to hospital with a nasty chest infection. A few days later we heard that he had died in hospital. I was in Gobabis on the way to visiting the hospital when I had to do a double-take as Chief was walking down the street whistling and carrying his weekly shopping. Our translator shouted him over and he explained that he was feeling great, having had antibiotics for 5 days and was discharged that morning. It is almost impossible for the San community to know what happens when someone goes into hospital when they are unwell. They assume, often rightly, that no news is bad news and that the longer the patient doesn’t come back to the village, the higher the chance is that they have died.

Outreach at a local school

The psychiatry department in Windhoek were excellent with Anton and he has been started on treatment. Unfortunately he needs assessment regularly for the first few months, which requires more midweek trips to Windhoek. Perhaps us not taking him to be assessed earlier appears neglectful. Maybe taking him at all appears to be a waste of resources. At the clinic we have to think about where our resources are most useful, with the time and money we spend on one patient coming with opportunity costs for other patients. There will not be any TB work done on the days we take him to his psychiatry appointments so there is a chance that a patient with TB could have been found and diagnosed that day. It is a difficult choice and I’m less sure now than when I started about what is right. A personal example of the Dunning-Kruger effect in action.

Two of my staff wearing their traditional Herrero clothing

I arranged the first ever Omaheke San Football Tournament a couple of weekends ago. I say Omaheke, our region, but there weren’t any teams from the south of the region as I don’t have such great football contacts there. Also Wikipedia says that a tournament involves ‘a relatively large number of competitors’. That is quite a stretch, as the 5th team dropped out the night before the tournament due to a funeral. Perhaps the Northern Omaheke San Football Playoff is a more down to earth title for the competition that was played. I spent some money that had been kindly donated from Canada on footballs for each of the teams, banners, lunch and dinner for all 60 players, a trophy and some prize money. Surprisingly for me, the most popular offering was the trophy. The other teams were so excited by the rumours of a trophy that during the week prior to the tournament they sent delegates to inspect it, before reporting back that they had to ‘train hard to win Doc-tah’. Considering the poverty that the San live in, I did not think the food and prize money would be side shows to this trophy. It reminded me of a trophy I still have somewhere at my parents’ house from when I was awarded ‘Most Improved Player’ at Under 9s football. (‘Most Improved’ = tries hard but zero talent).

The secondary school closed for holidays a week early, which was a slight disaster before the tournament. As my players are almost all school children and come from up to 180km from my village it was going to be a nightmare for any of my players to get back at all. Six of the most ingenious ones solved that problem by ambushing me late in the afternoon on the Sunday when I had just arrived back from Windhoek. They had ‘missed’ their transport back to their villages and now that the school hostel was shut, they had nowhere to sleep and could I let them stay. After discussing with Clare and our nurse Anna, we decided they could stay in one of the empty patient accommodation rooms for the week. In return they had to work hard in the garden all morning and then could go and train for the football tournament in the afternoon. 

One night during the week our patient accommodation rooms were full with patients so they had to sleep in the small living room area just off my bedroom. Their intentions were exemplary but I inspected the damage in the morning with our gardener/handyman (and fellow member of the football team) Fricky. All of the curtain rails had accidentally come away from the wall, the towel rail was pulled off the wall and there were tea spills all over the floor. They were also super thoughtful when using my ensuite toilet during the night by not turning the light on. Unfortunately the pitch black didn’t help their aiming and there was almost certainly more pee on the floor than went into the bowl that night. Fricky clicked the same San word at me twice as we surveyed the damage. ‘Baboons, Baboons’ was the translation. I laughed a lot as he continued to be slightly annoyed at his friends for the extra work they caused him. They’re such amazing kids and I’m sure they didn’t mean to cause damage. 

Half time

The tournament was a great success with the remaining 4 teams, thanks mainly to the hard work of Clare and the translators who helped with all the food, transport and community engagement.  All the teams got to play each other in 65 minute matches with the matches being super competitive and close games. The food we cooked on open fires in large potjie pots was gratefully received by the players between matches. My Lifeline Clinic Youngstars team won all three of their matches 2-1, 1-0 and then 2-0 so they won the tournament. They were the most excited that I think I’ve ever seen any San people and made us take a million photos. The party back at the clinic involved large amounts of Coke, Fanta and Sprite to celebrate, dancing to loud music and more photos of them drinking ‘cool drinks’ from the trophy.

Omaheke San Football Champions

The longer I’m working in Epukiro, the more I enjoy it. Longer periods spent here is more rewarding mainly because it is working with the San. When westerners think of ‘African tribes’ they often think of the stereotypes of them being happy and outgoing, welcoming you with open arms into their houses, eagerly showing you their culture, and being ‘happy despite their circumstances’. The San are the opposite to that – intensely private, unwelcoming of strangers, without obvious outward displays of emotion and carefully protective of their culture. This leads to a gradual, grudging acceptance by the community that makes it all the more rewarding when progress is made. 

TB, North Korea and the best weekend of my life

 

The final preparations for our STOP TB project are in full swing and I’m super excited for it to start. It looks like because of delays out of our control, I probably won’t be implementing any of it. I’ll have to be content with just planning and preparations. The main idea is to diagnose patients with TB in their own communities, in areas that they would otherwise struggle to access healthcare. It is similar to what I have been doing this year but fully funded and resourced. The only worry I have is that I’ve stitched up the next doctors, setting the targets for new TB diagnoses too high. I’m sure the new doctors will be great though.

A TB education drama performance for World TB Day

The STOP TB project also includes camping trips to increase the distances away from the clinic that we can reach. Recently I went on a trip into one of the most rural areas of our region, called Eiseb. We drove for hours down sand tracks, finding pockets of San working on the remote farms there. About an hour before dark the workers at a farm we were visiting allowed us to stay overnight within their rickety fenced compound. We collected firewood and cooked a rice and meat based meal in a potjie pot over the open fire.

Camping in Eiseb

The farm worker had told his mates from neighbouring farms that they had guests, so by evening we had a circle of sixteen people around the fire. There were rumours of cold beer being sold in a shack up the hill so we drove in the dark to find this mystical place. It did indeed sell beer but sadly not cold. The temperature reminded me of the water temperature I have my hot showers set at. Even so it was a fun evening, eating, drinking, listening to music and talking in slightly limited English. The farm we stayed at, Okaripuri, was 3 hours drive to the nearest road, 5 hours drive from the clinic, 7 hours from the nearest hospital and 9 hours from Windhoek.

A recent positive outcome I had was with a 5 year old girl that I had taken to hospital a few times trying to get her diagnosed with TB in her elbow and lymph nodes. The actual clinical history was quite complicated but in the end she was started on TB treatment. Since then her elbow has massively improved, her lymph nodes have disappeared and her body weight increased by 15% in a few weeks. Sometimes I think that my TB work here is futile as the causes of TB in the San (malnutrition, overcrowded housing, poor access to healthcare, poverty) mean that there will continue to be many TB diagnoses for the foreseeable future. Small successes like this girl remind me of the importance of clinical healthcare in remote settings.

An interesting thing that I have been reading about recently is Namibia’s close link to North Korea. I read a half page advert taken out by North Korea in one of the Namibian national newspapers that was extolling the virtues of Kim Jong Un and railing against the aggression of the USA. Talking about Kim Jong Un in the national newspaper: ‘True to their expectation and desire, he became the shining star adding glory to Korea. Adding glory to Korea and carrying forward Kim Il Sung’s cause – This was his lifelong mission.’ There is also a really weird Namibian history museum in a giant gold teapot of a building, towering over Windhoek that is a bit of a running joke. It was built by the North Koreans for an unclear reason, with the inside being a strange homage to the Namibian war of independence. It has no clear timeline or information except crazy murals of battle scenes and random war memorabilia. I left the museum more confused about Namibian history than when I entered.

I read slightly more about the North Korea/Namibia connection. There possibly was some support from North Korea for SWAPO in the war of independence, though other sources say it was mainly a close personal friendship between Kim Jong Il and Sam Nujoma (the first president of Namibia). As recently as last year, Namibia was very close to breaking UN sanctions, working with the North Korean army in shadowy arms deals. Check out these interesting articles here , here and here. A final UN decision cleared them of violating UN sanctions on what appears to be a technicality about dates. One of Namibia’s main exports is Uranium, I do hope there is no connection.

‘Lifeline Clinic Youngstars’ as they have chosen to call themselves

I took my football team to the farm of the wildlife charity that is the parent charity of the clinic I work at. They employ mainly San workers and have a San football team as well. We transported my team of 14 players in a Toyota Hilux 4×4 to Windhoek (to which many of the boys had never been). On the Friday we were taken around to see the animals. On seeing the lions, the noise level from the boys was a tiny bit too high and a lion roared and fake charged at the fence. Three of the closest boys ran off terrified, one of them running off into the bushes so fast that his hat blew off behind him. After a final football training session on the Friday evening we slept in a tent in the San workers’ village.

Prior to the big match

On Saturday we were kindly sponsored to take them to the cinema. The film we watched was King Kong in 3D and they loved the silly glasses they had to wear for the 3D. When they came out, one of them asked me whether King Kong was real and whether it could come to Namibia. Perhaps I was ambitious thinking that my San school kids from remote villages, with variable levels of English, were going to enjoy the cinema. A week later I asked two of them to explain the storyline of the film. I laughed so much as they worked together trying to explain King Kong with their limited vocabulary of English, arm movements and sound effects of the monster and the planes. The thing that made more of an impact than the cinema were the escalators. A few of them just watched people going up escalators for a while, then were too scared to go up themselves. They also really loved the changing pictures of the digital adverts in the mall. A couple of the guys wouldn’t let us leave the mall until we had seen it change one more time.

Excited by their blue tongues

The football match on the Saturday was amazing. I had managed to get my best team together and the match with Naankuse (the wildlife charity) was very even. Before the match, the staff that I knew at the farm were making fun of how small and young my team was. After the match they were full of praise of how skillful and good for their age they were. The game was 1-1 at full time and sadly we lost 2-1 in extra time. One of the boys on my team apologised to me afterwards, saying sorry for wasting my time in bringing the team all the way to Windhoek just to lose. I tried to explain that it was the taking part that counts but he wasn’t having any of it. I asked each of them a few weeks later which was their favourite part of the weekend. A really popular part was Saturday lunch in Windhoek which was a hot dog, popcorn, and a can of coke. The lunch was in a lovely setting on hotel grounds and they said that they felt like they were ‘posh’.

I can’t really describe how much fun it was with the team that weekend, playing the football match. It’s certainly up there as one of the best weekends I’ve ever had. I love spending time with the team of school kids (most are 16-18) though they still all insist on calling me ‘Doc-Tah’ in their amazing accent.

 

 

Ju|’hoansi, education and car accidents.

Towards the start of February, having left behind my marginalised Ju|’hoansi San patients less than 24 hours before, I found myself in London in a corporate box watching an Arsenal football match. My friend had kindly provided me with free tickets through his work and I sat there watching the match in the snow, drinking beers that cost my friend’s company £5 per bottle. The contrast from Epukiro to the Emirates could hardly be greater. Thankfully I was given a job from the world’s most expensive interview and I’ll be moving from rural Namibia to inner city London in July.

‘Oma’ – San for grandmother

My friends and family have been making fun of my changed appearance since setting off for Africa over a year ago. Before I left I was a regular at the gym and played squash a few times a week. Since being in Namibia I’ve barely done either and I’ve lost about 5kg of muscle. A lovely comment from my Mum when I was back at Christmas was ‘You look very skinny Paul, are you sure you’re not sick?’ The culmination of this was in a supermarket in Namibia in the local town. Not playing squash has made my legs like cocktail sticks and I’m still wearing the same size trousers as before. I was queuing up to pay when my shorts fell down. I drew a lot of attention from the long queue of people behind me as I loudly dropped the cans of sweetcorn I was carrying on the floor. I was carrying the rest of my shopping in my arms, so before I could bend down to pick up my shorts I had to carefully place my bag of apples, my avocados, diet coke and giant box of rooibos tea on the floor. I was the only white guy in the supermarket, shorts by my ankles, showing off my bright purple underwear for about 15 seconds.

Drinking at the local bar

Some excitement for the village recently was with a snake in our grounds. I was walking through the clinic yard with our San translator when she somehow noticed a track in the sand. She looked at the track, said there was a snake and that it led to a thick patch of grass next to our house. Sure enough when she had a look, a Boomslang snake slithered out, past the open door to our house and into the bushes. The villagers here do not appreciate a deadly snake next to their houses. It sounds lovely for conservation to let snakes live free, but it just takes one child being killed for the snake’s wellbeing to take a back seat. The next hour and a half was spent with villagers throwing rocks into the trees and bushes to try to force the snake out. They threw petrol into the bushes and set them alight to try to smoke it out. The standoff was eventually broken when the snake made a successful mad dash through the bushes leading towards the river and safety. We now have to keep all our doors and windows shut as the snake has been seen on our neighbour’s property a couple of times since then.

I’ve had some generous donations of money recently to spend in Epukiro. I’ve had to think carefully about how to spend it since money doesn’t solve problems here and can actually cause more problems. A volunteer at the clinic gave a mother with a small child the equivalent of £3 (a huge amount of money here) as she said she was hungry. We found her later, passed out, with the baby still on her back, having spent all the money on alcohol. Anther example is a San child that made it to Grade 11, which is an incredible achievement. A Swiss charity heard about him and started giving him money while he was at school. He dropped out of school within 3 months, spending all the money he received on alcohol. He’s now an alcoholic in the local town.  

A day of TB active case finding with my translator

 

Despite that sad story, my opinion is that education is the only way that the tough situation the San face in our area may change. There is a secondary school in our village and I’ve spent time with most of the San boys and girls that attend there, through my football team or the San cultural dancing group. They told me that they don’t have many of the basic necessities for school. They regularly mentioned not having school uniform, an obvious way that the San stand out as being poorer than the other tribes. The schoolchildren were excited when I used the donated money for school uniform, school bags and stationary for the 35 San students at the school. School uniform doesn’t mean they will go on to academic success but maybe it could make them feel more like the other students at school, and feel more pride in belonging to the school. 7% of San children finish primary school and less than 1% finish secondary school (at age 16). We don’t know of a single San student in our area that has passed Grade 12 (at 18) in the last 5 years.

Proud in their new uniform

There are four San students in Grade 11 and 12 in our region at the moment and my translators knew one of the girls. I was introduced to her and since then I’ve tried to support them with some school equipment like calculators, textbooks and school trips. They often don’t have toiletries so I took one of the boys, Isaak, to the supermarket. I had spent £20 on soap, toothpaste and other items for the four of them. Isaak said to me ‘I feel pity for you doctor, spending all this money on us.’ I guess he could not see a reason why I would spend this huge amount of money on children I wasn’t responsible for. I felt guilty that I had spent £20 at Christmas on two Cosmopolitans while out drinking in Manchester.

The football team had only one match in February as I was away a few weekends and we now share the car at weekends with ‘Doctor Clare’s netball team’. We added to our losing streak, losing 3-2 to Pos 13, which makes it four losses in a row now. In March we’re going to play against the Naankuse farm team in Windhoek (the parent charity of the clinic I work at, which also employs San people). The boys are super excited about it, some of them never having travelled more than 100km from our village before. The netball team is awesome as the San girls don’t often play much sport. Again, like the boys, they just aren’t able to compete physically with the taller, stronger Herreros. Clare takes them to the same villages I go to, to play against the San netball teams there.

The Epukiro Pos 3 San Netball Team after winning their first match

In a sad end to the month, there was a car accident involving a white farmer from our area. He had his San workers in the open back of his 4×4 and his dogs in the cab with him. His dogs survived and his San workers died in the crash. A story of how undervalued San lives can be in this remote area of Namibia.

 

Kalahari dreamin’

In a good way, it felt like I’d never been away when I returned to the village in January. Our new doctor Clare is great and having a second doctor again takes a lot of the pressure off. The translators managed their money reasonably effectively over the holidays so I didn’t come back to angry villagers waiting for me to pay off the translator’s debts.

Brightly painted house under an imposing sky

January to March is the rainy season in Namibia and the weekly thunderstorms are super intense. The long, dusty, sand tracks that I left in December are now often turned into streams running down the gentle slopes of the Kalahari. An unfortunate consequence of this is that our newly built staff accommodation flooded in the heavy rain. The buildings are now protected by our home-made sandbags until we can alter the flow of water. I hadn’t seen a drop of rain for 7 months and when I arrived back after Christmas my house was flooded. How ironic. (sic)

It’s obvious how much harder life is for the San with the extremes of weather. It’s fine for a tourist to say they like hot weather, but they don’t live in a corrugated iron shack, unable to leave the shade as they don’t have shoes to walk on the unbearably hot sand. You could say that you prefer to be too cold than too hot as you can always put on more layers, but not if it’s -5 degrees and your entire family sleeps under one blanket. ‘A bit of rain never hurt anybody’ is true I guess, unless your hut isn’t waterproof and your entire possessions including your important documents become waterlogged every time it rains.

The view as we finally found where a child lived, after he had spent time in hospital

January is the start of the new school year. I had been spending time with the schoolboys and girls over the previous 7 months with their endeavours with football and San cultural dancing respectively. I was so sad to be told that less than 25% of them passed the year, and only about half of them had come back to school this year.

Grade 10 is the equivalent of GCSEs and is an amazing achievement for the San in our area. There were three San girls in Grade 10, all of whom failed the end of year exams in December. One is now heavily pregnant and the other two have jobs babysitting in Windhoek. I spoke to the girl that I knew best, trying to persuade her to come back to school. Obviously the myriad reasons that she gave up school meant that I didn’t succeed. My western arrogance thinking that I could change the situation with some words of encouragement and an offer of financial help, was wildly misplaced.

There are so many reasons that school is tough for the San and finishing education is an insurmountable task. If anyone from a high income country thinks they are successful solely because of their own hard work, they need to see life here. Even the most naturally intelligent San child, with the best work ethic and determination doesn’t get an opportunity to fulfil their potential

On a more positive note, I was able to help a boy start school again after talking to him when he played for my football team. His main problem was with money and school uniform, which I can sort relatively easily. I took him to Gobabis with me one day to pick up his academic report, so he could register at the school in our village. I’m under no illusions that this will change the course of his life but perhaps a small positive might come of it.

Two of our translators comfortable in the back of the 4×4

We’ve had more fun with my football team in the last few weeks. Three narrow losses in a row in January has brought the team’s sky high aspirations down to earth (after winning three in a row before Christmas they asked whether they were the best San team in the country). My best player hasn’t been able to play as he can’t hitchhike to our village easily in the rain, and the best defender has dropped out of school. I had a great time giving out the donated football boots from Orkney and am currently looking at setting up a San football tournament before I leave.

Life isn’t always glamorous here. I recently had to take de-worming medication. Don’t ask how I knew but it had to do with a toilet brush. I also had an unfortunate escapade with scabies. These horrible little mites jumped ship from a delightful child I was examining and left me unable to sleep because of how itchy they are at night. Another moment that I had to reassess my life was at 1am one night, paddling around in sewage water, holding a torch for my friendly Namibian neighbour as he unblocked our septic tank pipe that was overflowing. At least when I looked up at the sky in exasperation at the situation, the beautiful night sky including the Milky Way, made my problems seem very small again.

Outreach at a school in a remote village

Probably my most interesting patient since I’ve been back in the village involved squeezing 10 tumbu worms (no relation to the maize based alcohol sold at the shebeen) out of a guy’s abdomen and thighs. I didn’t know what the holes in his skin were, but my translator told me that there were worms living in there. I squeezed gently and the rear end of a cream coloured worm poked out. I squeezed harder and a fat, juicy worm came out and landed in my gloves. Tumbu worms are pretty disgusting but rather satisfying to remove. The patient asked me how he could stop it happening again so I looked it up. He has to iron his clothes after hanging them out to dry. His daily problem of not having enough food to eat meant that having an iron, or electricity for an iron were lower down on his priority list.

I’m back in England for a few days next week to attend a 20 minute interview for a job later in the year. Total cost for the planes and trains: £1000. I think £50 a minute seems a bit steep. I’ve now advertised for the doctor that will replace me in June. Sadly the slow timescale of the STOP TB funding will mean that I probably won’t get chance to work on the project myself. I’ll be involved with the set up but I’m jealous of the busy and interesting year the next doctor has ahead of them.

Enthusiastic lady waving while waiting to be seen on outreach

Christmas desserts

In December, Naankuse ran a Conservation Medicine course and then the clinic closed for a few weeks at Christmas. The start of my month therefore included a mad dash around the desert finding the TB patients that are least enthusiastic about taking their pills, refilling their medications for the time that I was away.

The Conservation Medicine course was great fun for me to be part of. It was a mix of animal conservation, remote medicine and desert medicine. Activities included helping dart then transfer a cheetah between enclosures, seeing a deadly Black Mamba snake from a metre away, and a desert hike with medical trauma scenarios. One of the nights was spent sleeping next to a low burning fire (to keep the leopards and hyena away) in a dry river bed in the Namib Desert, looking up at the shooting stars. Magical.

Cheetah transport

My part of the course was to talk to them about TB, HIV and remote healthcare. In the afternoon I brought in the patients I thought were interesting, to discuss and examine. A recurring theme came up in discussions about whether it was worth investigating certain patients. One young female had difficulties with co-ordination and walking due to a problem in the cerebellum of her brain. We agreed that whatever it was caused by, was unlikely to have a cure so the weeks she would spend in Windhoek hospital were not in her best interests. Another had a badly deformed ankle and lower leg, possibly after childhood polio. He could still walk on it and wasn’t in significant pain, so again the consensus was that it was unlikely to be worth the investigations and surgery at the moment. It doesn’t help that I still can’t find a way to track my patients once they’ve gone into Windhoek hospital. They become lost on a mystery ward there and I can’t find them until they turn up in the village weeks or months later.

A family photo on a remote farm

Closing up the clinic for a few weeks meant that I had to give my translators their wages in one lump sum while I was away. They generally aren’t the best with money, and certainly not with saving any of it. I was slightly concerned giving them all this money at once, so spent ages one afternoon giving them basic financial education. The theme was along the lines of ‘These are your normal wages. You have no more money than usual. Don’t spend it all at once.’ I was all smug about this foresightedness and my successful intervention, until one translator came into work the next morning telling me she had just spent 2 weeks wages on a dead goat and was inviting the village to share it tonight.

In the middle of December I found out we were successful with the bid for funding from the STOP TB organisation. Only 7% of applications were successful and most of these were huge organisations such as the Clinton Health Access Initiative, or Partners in Health (which has 18 000 employees compared to our 8). Our award was for US$ 100 000 to expand the TB project that I’m currently working on. It allows me more time and resources to work in the rural farms and villages, including overnight camping in these remote settlements. I can’t wait to start and I’m so excited to see all the interesting places that were previously too far away. The end outcome is hopefully going to be a big increase in our TB diagnoses, with the aim of breaking the cycle of reinfections.

A house in Donkebos, the place from last month with the water problems

I’ve been away from home since March 2016 and it felt strange being back over Christmas. The difference in priorities was obvious straight from the airport. I was on the bus passing a Gucci shop and was pretty upset by a woman carrying multiple bags of Gucci products. How could she justify to herself that there was literally nothing else in the world to spend those thousands of pounds on? The best possible use of her money was to buy some clothes to show off how rich she was to other people. I imagined her going to the children in my village, looking them in the eye and saying that the money that would change their lives, was better spent on a new handbag. I am aware that this is obviously stupid as she hasn’t met the children of Epukiro and she is just a product of her surroundings, but still…

I really want a new iPhone. A brand new, gold, top of the range one. I want a new pair of Nike trainers and a new Ralph Lauren shirt. Why am I any better than the lady at the Gucci shop? I’m not I guess. I’m a giant hypocrite, left with more questions than answers about what’s important in life from my time in the village. It’s also certainly not fair to judge people for living the way that society in the U.K expects them to. I’m not going to start judging the life choices of my friends or I’ll end up a lonely old man, swimming in a sea of self-righteousness (as if I’m not bad enough already).

Warthog pitch invader

I worked for some time in the Orkney Islands over Christmas to earn some money to afford my flights. While I was there I put an appeal in the local paper for second hand football boots. Over 50 pairs of football boots and trainers were donated and most of them will get out to Namibia with me in my excess luggage. There is my team and then three others that we play against regularly so I should be able to provide shoes for most of the players. Also, my 8 year old neighbour donated me his Christmas present of a new pair of football boots. He calmly stated ‘They don’t have as much as I do, so I’d like someone in Namibia to have them’. There was no way as an 8 year old I’d have given my Christmas present away. What an ace child he is. Hopefully the boots can reduce the amount I have to stitch up cuts on the players’ feet from glass or sharp rocks.

Some of the football boots and trainers from Orkney

I’ve also had a generous cash donation from Canada. I’m still planning the most effective way to use the money, as the problems the San face are complex and simply throwing money without thinking doesn’t work. Supporting the San secondary school kids as much as possible is one idea. When I’m back I’m going to speak to the headteacher to find out which San children failed the year and dropped out of school. At the weekend I’ll be driving round the countryside to try and see them, find out why they dropped out and see whether I can persuade them to go back to school. I see little improving for the San community at the moment and these secondary school children (only 6% of San kids make it as far as secondary school) are where I see some potential successes.

Lastly, a new doctor is starting work with me in January so I’m excited to meet her and show her the bright lights of Epukiro.

Brit abroad in my Mum’s gardening hat

 

‘You don’t want it to rain in the desert’

Well actually we do want it to rain in the desert after the drought of the last few years, but it makes all the travel around here much more difficult. November has been a rather busier month for me out in the desert. Sarah, the doctor I’ve been working with since June, has finished after 16 months here and I’m on my own until January. Running a rural clinic in Africa is rather more work than I realised as Sarah had previously made the admin side look so easy.

Outreach set up in a village pre-school.

Activities at the end of last week included: pushing one of my translators around the village in a wheelbarrow as she had hurt her knee the previous evening and couldn’t walk to work, arranging for a company in Windhoek to renew the license on our out of date fire extinguishers, turning the water off at the mains as there was a giant flood coming from a rusted flexi pipe in one of the clinic toilets, transferring a baby to hospital that was breathing at a rate of over 100 breaths per minute, and finding a second-hand phone to give to my star football player to contact him before a big match.

It sounds strange writing it or even consciously acknowledging it, but every single one my San patients goes hungry. The average BMI for our clinic patients is around 15 (expected to be 18.5-25) and we adjust drug dosing due to the average weight of a woman being 35kg and a man 40kg. This hunger is ‘normal’ for me now but at the start of November I experienced water insecurity in Namibia for the first time. As an upper middle income country, 6 times as wealthy as Kenya, I am sometimes surprised at the issues I come across. This is perhaps due to its GINI index ranking as the second most unequal country in the world. (Recommended reading: The Spirit Level by Kate Pickett + Richard Wilkinson, and The Price of Inequality by Joseph Stiglitz). Despite my reservations about its high level of inequality, Namibia along with Botswana is a shining beacon of democracy and stable economic growth in Africa.

The water problems I saw were when we were providing our outreach clinic at Donkebos. This is a San resettlement village deep in the Kalahari, where we found they were having huge problems with their boreholes. At least half of the patients had medical problems directly related to lack of water. Children with headaches, older males with low blood pressure, younger women fainting. I asked one woman how much she had to drink the previous day and she replied with ‘one plateful of water in the morning, and one plateful in the evening’. Measuring water consumption in ‘platefuls’ when the temperature is 40 degrees during the day is madness.

Other patients were unwell indirectly from the lack of water. Diarrhoea was common as there was no spare water to wash their hands after defecating. I enjoyed the aftereffects of this after sharing my water bottles with the patients, spending the weekend on the toilet or feverish in bed as punishment. My friend working for a San NGO and I are still looking for a solution to the broken borehole problem so if anyone has a spare $15 000, then we’d love to hear from you.

Girl + bow the size of her head.

The football team has given me more enjoyment this month. We’re on a 3 match winning streak now, but the highlight was playing against Skoonheid a couple of weeks ago. Skoonheid is possibly the best San team in the area and was the team that had beaten us 7-1 last time. I’d collected all my best San football players from around the village and set off for a Sunday afternoon match. I started off as the glamorous linesman again but swiftly had to become referee when a giant thunderstorm caused the original referee to run off seeking shelter.

The pitch had gone from a dry sandy dustbowl one minute to a boggy pitch covered in puddles the next.  My team, mostly made up of schoolboys compared to the adults of Skoonheid, played amazingly and won 5-3 (I’m pretty sure two of their goals and at least one of ours were offside but there were no linesmen who would help me). The San are very understated and don’t show much emotion, but this time my team’s enthusiasm at winning showed through.

This is our stormy football match as seen from the shelter.

I sometimes feel guilty that the volunteers that are with me while I’m working with the San edge towards poverty tourism when taking photographs. I don’t think it is necessarily deliberate but the San often don’t get much back for the photos that are taken. To change this I try to encourage our volunteers that are here longer to print off photos when we’re in the local town and give them out to the San who are in them. The photos that the San families do have are treasured. A family that lives on a farm near us proudly show us their photo scrapbook from around 15 years ago when we visit.

Recently the father of Sara, the girl I was sad about when she died last month, came to me in the village to thank me for trying to help her. One of our volunteers had taken photos of Sara with her family when she was still well and had printed some of them out. When I gave them to him he was overjoyed, showing the photos to the friend he was with before his San stoicism and reserved nature returned. He thanked me again and walked slowly away to catch his hitchhike back to the farm.

The matriarch of Otjizombaka

I have terrible trouble with patient names while working here, often when trying to find patients that are sputum positive for TB (confirmed, infectious TB). My patients always have a San name which usually involves a click, and then an English name given to them. Patients will sometimes be known by their San name or sometimes just by their English name. There can be different spellings of the same name so a common surname such as Khao, can also be spelt Kao, Xhao, Xao all pronounced the same and used interchangeably by the same patient. One of my translator’s surnames is Kashe on her ID card (her father’s surname) but she always writes her surname as Kleinbooi which is her mother’s surname. Many patients don’t have ID cards as they are only necessary for admin tasks such as collecting pension money.

A regular occurrence of being stuck in a village with a flat tyre, being helped by the villagers.

Another complication is patients having absolutely no idea how old they are. I guess if you were born on the floor of a shack on a remote farm 50+ years ago, why does it matter how old you are or when your birthday is? I often have to guesstimate ages and write down their birthday as the 1st of January on forms. A regular occurrence would be a patient coming to the clinic without an ID card, with a first name of San clicks that we struggle to translate, unsure how to spell their surname, unsure how old they are and unable to say where they live as they move around to different farms so often. Extra challenges in the desert.

Sun, Sand, San, Sadness

My area of the Kalahari Desert has become super hot in the last month. I know some of you may be thinking ‘you moved to the Namibian desert, what did you expect?’ but this is on a whole ‘nother level to Scarborough on a sunny, summers day. It was 41°C yesterday and still I’ve had friends say to me ‘Oh, it’s dry heat, it’s fine’. It’s not fine. The heat and wind evaporate the sweat so quickly it’s easy to forget to drink enough. That leaves me at about 3pm with a mouth so dry that I feel like I’m chewing the sand I’m walking on, and my pee a rich mahogany colour.

One of the families I love visiting, deep into the Namibian sandveld.

Life is tough for the San here. The children at school tell me the stories of how badly they are bullied, another one of our female patients was raped the other day, and the uncle of a guy I hang out with was killed in a fight over a pack of matches. I feel guilty that I can’t do more for this community. I feel guilty that they let me enter their lives and I choose to leave again a year later. I feel guilty when I buy an ice cream for my paediatric patient who is in hospital with TB. It feels pathetic that this is all I can offer a child with a disease with a 15% death rate, an alcoholic mother and no formal education. Buying the ice cream really just allows me to distance myself from the difficulties of her life by providing a small moment of happiness.

My first time seeing a traditional San hut.

The photo above is from a farm about an hour and a half away that had a number of San people there and possible TB cases. We had an awesome adventure there in October that involved some great off-road driving, a rare sighting of traditional San huts and a couple of new cases of TB. At a follow up visit there with Anaki, my usual translator, all the older San there recognised her. They were her mother’s family but hadn’t seen each other for 15 years.

My favourite patient died last week and it was the most upset I’ve been since becoming a doctor. She was in her early twenties and was the most amazing person. She was funny and kind, spoke excellent English and had avoided all the pitfalls that young San succumb to: alcohol, smoking, teenage pregnancy, dropping out of education. She was fascinated when we talked about my blog and how people in the U.K were reading about life in Epukiro. She was everything that was positive about a young San person – yet still she died.

Maybe things would have been different if she hadn’t lived in a tiny, remote village. Maybe a different doctor would have requested different investigations and found the cause of her disease. Maybe nothing would have changed the outcome. Previously when I was working as a doctor the ultimate responsibility for a patient was always with someone more experienced, but here there is no-one else. RIP Sara, I feel like I failed you.

Gym and sauna.

My football team has won its first match! It was a revenge 5-2 win against Pos 13, the team we played in our first ever match. (Previous losses of 5-3, 3-0 and 7-1 to three nearby villages). The original team from when I started has changed as the players have gradually moved away. One of the previous doctors performed population surveys on the San in my village one year apart. The population remained stable but only a third of the people were the same. Two thirds had moved on to live in different places. They move to remote farms to find work, as well moving to visit friends and family in different settlements. This mobility is almost unique in Southern Africa and makes for difficulties providing healthcare, as well as my attempts at managing a San football team. The options for the San guys once they drop out of school here, involve drinking alcohol at the shebeen every day or manual labouring on remote farms. Neither of these is conducive to creating a formidable San football team.

From  Left  to  Right:  Chapo,  Philip,  Okeri,  Thomas,  Jantjies,  Tari,   Johannes,  Clifton,   Me,  Fricky,  Anton,  Petrus,  Ice,  Chris,   Otto.

 

I absolutely love the days out when we visit the local villages to play football. They’re such fun days, despite the fact that I’ve been demoted to linesman now since our team improved so much. Jose Mourinho here also sent on all my substitutes in the last game at half time, wanting them all to get a fair time on the pitch. One of the guys was promptly injured so I had to change out of my flip-flops, short shorts and sunglasses, and into the team kit as a poor attempt at a left back.

We also have a new recruit that hitchhikes 70km from where he lives to join the team at the weekend. He was invited for trials for the Namibian under 20 team last year but his family couldn’t afford to send him to the trials. He’s by far the best football player I’ve seen since I’ve been in Namibia despite his tiny, half-San half-Herero frame. A highlight for the team recently was playing against the local wildlife lodge that employs San workers. After the match I was able to take them round to see the lions, leopards, cheetahs, wildebeest and various other antelope. My San ‘bushmen’, renowned for their knowledge of the plants and animals of the Kalahari, had never seen any of those animals.

Excitement for November includes running the clinic on my own, teaching on a course about conservation and wilderness medicine, and finding out the result of our STOP TB funding bid.

 

 

International fugitive

A ‘minor’ oversight on my part back in June on leaving South Africa has complicated my travel plans for the next year. I confidently strode up to the immigration official at Johannesburg airport to leave the country for the final time only to be told that my visa expired the day before. Cue an awkward, intense interview in a prison-style windowless room, a slap on the wrists and banishment from South Africa for a year. I tried sending an email afterwards to contest the punishment. I stated how important a tuberculosis doctor I am in Southern Africa, and the need for me to attend conferences  in South Africa (I’m not and I probably won’t) – the silence in response has been deafening.

The ban normally wouldn’t be a huge problem as I don’t often visit South Africa, but while I’m in Namibia it is by far the easiest country for me to travel to on my time off. Every long haul flight from Namibia stops in South Africa and I’m now banned from leaving the airport. Every long stop-over I have, I have to remain in the airport like a British Tom Hanks from the film The Terminal.

The matriarch of one of the villages we visit

One of our outreach sessions recently was to a village we hadn’t been to before called Vergenoeg. The journey there was longer than most of our outreach locations but the welcome more than made up for it. The school principle arranged his 150 schoolchildren to sing a welcome song to us, then I had to perform an impromptu speech (via translator) from the principle’s lectern.

The amount of untreated medical problems was huge: we saw horrible infections due to lack of access to antibiotics, obvious cases of TB, wildly uncontrolled high blood pressure, severe lung problems and fungal infections in children. There were so many patients to be seen that we had to return the following week.

The second visit was notable for the fact that the ambulance broke down. Vergenoeg is in the middle of nowhere, 3 hours from our village. I had to walk 2km up a hill to reach mobile phone reception and then waited 5 hours for the rescue team to arrive. We were waiting in the complete darkness in a small village in the middle of the Kalahari for hours, finally arriving home tired and hungry around midnight. An advantage of this interlude, was that during the afternoon we had extra time for all the San patients that queued up to be seen. Anna, our nurse and I saw 78 patients during the day.

A scene when I visit one of my TB patients on a remote desert farm

A few weeks ago was the measles vaccination campaign for our area. Sarah, the other doctor and I had to have our unnecessary measles jabs again, then our little finger nail marked with indelible ink. This was to prove to the community the benefit of the injection. Trying to explain to the villagers with limited or no education the benefit of herd immunity, or the serious complications of cerebral measles is difficult. Showing everyone that the doctors had been vaccinated was much easier. Next week there is a circumcision campaign (to reduce HIV transmission) that I am keeping as far away as possible from.

The San football team I set up for my village had their first match yesterday. We played against the Pos 13 San team who were an altogether more serious outfit. They had a manager, a team kit, substitutes and were drawing lines and positions in the sand in a pre-match team talk. We arrived with mismatching shirts (I’ve ordered our new blue kit but it hasn’t arrived from Windhoek yet), only 11 players and decided which positions we would play in the minute before the match started.

Pos 3 team + our current medical students

I had arranged for kick-off to be around 10am as the temperature goes up drastically soon after. After rounding up all my players from various houses in the village, driving 40 minutes to Pos 13 and then rounding up all their players – kick off started perfectly at midday. We played for 90 minutes in 35 degree heat without any drinks breaks except half time. I nearly died. Considering how unprepared we were compared to the organisation of the other team, we played well. It was 3-3 until the final 5 minutes when I was taking my turn as goalkeeper. I spilled a routine cross straight to their striker who was delighted to be presented an open goal from 1 yard out. We ended up losing 5-3. I spent the evening watching goalkeeping errors from the Premier League, trying to console myself. The guys seemed to enjoy it though and will be super excited when the new team kit arrives and we start training for our next match.

There are many social problems the San have here that support and money could change. One of the difficulties is who deserves support most with our limited resources? The San football team that might give the young guys some purpose and pride, the young adult with psychiatric problems that has to scavenge food from dustbins, the 16 year old girl – top of her class – that doesn’t have the money to finish her last two years of school in the local town, the hard working man who wants to be an entrepreneur but has no investment, my intelligent translator that needs to go back to repeat her last year of school in order to fulfil her dream of being a teacher, the 7 year old girl with cerebral palsy that is occasionally tied to a tree with a rope by her neck while her mother is drunk. I don’t really know, but the only real long term solution is concerted efforts at government level. What we are doing as a charity clinic is valuable, but ultimately only an sticking plaster on the open wound of the San’s social situation.

The house of one of my favourite patients

Lastly, the other day I visited a patient that we heard was unwell. They happened to be fine but described their neighbour as having coughed up blood. The teenage boy offered to show us and promptly set off into the Kalahari bush. He rode through the sand and thorn bushes on a bright white horse (no saddle) while we tried to keep up in our truck. To complete the slightly surreal situation, my translator Anaki was singing along with Backstreet Boys on full volume in the truck with me. That was one of my occasional moments that I stopped and thought ‘how on earth did I get here – following a man on a white horse through the desert while listening to 90s boybands?’

 

‘When God made Namibia he was angry.’

‘When God made Namibia he was angry.’ was how a Namibian once described the scenery of his country to me. Barring my atheism I agree. The majority of the country is stunning and desolate – world famous sand dunes, empty deserts, towering rocky outcrops and wild coastline.

Empty deserts with my friend Tom

 

Unfortunately, my area of the Omaheke region is less glamorous. It if flat, dry, sandy and populated by scrubby short trees and thorn bushes. I’ve already had to spend many hours driving the dirt roads in this landscape. On one of my first journeys I was confused by the tracks in the freshly graded dirt road. The tyre tracks were much closer together than usual and were weaving all over the road. I was expecting to turn a corner and see a drunk man in a tiny, tiny car. It was actually a cart pulled by a donkey with a family of 6 in the back, on the way to see us in clinic.

The view of my village from the only hill in the area

One evening last week I had to drive the 3 hour round trip to the nearest hospital in the dark (less than ideal with the accident rate at night on the dirt roads). Late afternoon a parent brought in their 5 year old child quite unwell. He weighed 10kg (average 20kg), had a haemoglobin of 3.2 (average 12.5) and a horrible chest infection. After leaving him attached to antibiotics, a blood transfusion, being kept warm and getting fed, I was less worried that he would die overnight.

5 days later I was in hospital again and checked in on him. He’d been diagnosed with severe acute malnutrition and tuberculosis but the change was incredible. He looked like a totally different child. He smiled at me instead of constantly either coughing or crying, showed off his dancing skills and gave me a hug when I was leaving. I have no idea whether he knew who I was, but seeing his improvement was one of my favourite moments I’ve had as a doctor.

Outreach sessions from the back of the ambulance

On a slightly less upbeat note, alcohol is an awful influence in our area. Our regular daily visitors are the kids from the shabeen. They are children aged between 3 (age of independence) and 6 (age they start school) that are like a heartbreaking version of Fagan’s gang from Oliver Twist. They hang out together, play together and look after each other. Their parents live at the local shabeen, which are unlicensed drinking establishments selling home brewed alcohol very cheaply. The parents spend all their time and money on the cheap alcohol and neglect the children.

The kids come to us for food, entertainment and for some of them, tuberculosis medication. It is a difficult situation though as hunger is widespread amongst the San in our village. It is unfair that we only feed the children with parents that make the worst choices. The effect is rewarding the parents, who then have more money to spend on alcohol or their own food. Even sadder though is when we don’t feed them and the parents give the child the thick alcohol from the shabeen to try and satisfy their hunger. This leaves us looking after drunk and vomiting preschoolers.

The shabeen children having fun

I’ve recently been in the process of setting up a football team for the San guys in my village. The gardener of our clinic has taught me which brands of football to buy to withstand the thorn bushes encircling the football pitch. The San aren’t explicitly excluded from the football played with the rest of the village but they don’t feel comfortable playing. Now they have a supply of footballs, the San play most days and I join them a few times a week. My parents are kindly bringing out donated football boots for the team when they visit soon, as they all play barefeet currently. Hopefully we are playing the local tourist lodge that has a San team in the next few weeks. I would like to have enough players so they can play and I coach, though I can’t speak the Ju/’hoansi San click language so maybe I can just be supporter in chief.

Again some smaller situations this month have been different to my life in Manchester. Yesterday, my translator and I were searching the countryside for the owner of a goat that I had accidentally run over while driving over the crest of a hill. When we found him we negotiated a deal of 2 packets of ibuprofen for the owner’s aging grandmother, and that we would take the dead goat in the back of our car back to his house. I had unfortunately forced them into a family party to eat the goat that night.

Recently I opened one of the fridges in the clinic and found a large chunk of meat in it. After asking around, it turned out to be half a dead warthog that one of the translators had been given as a present by a potential male suitor. A romantic gesture I’ll bear in mind if I’m ever starting to get desperate for a wife.

This San lady above had travelled with me on a journey . She was in the back in this picture but when some of my patients vacated the front, she joined me there. She was constantly smiling an amazing toothless grin at me, and was clearly excited to be in the front of a new car. The seatbelt alarm was going off as she didn’t know to put her seatbelt on. I tried to explain about seatbelts but our languages were far from compatible. I then reached over to grab her seatbelt and brought it half way across her. She grinned widely, poked her head enthusiastically through the seatbelt loop and hung on to the loose end as if her life depended on it. She looked so pleased with herself that I barely had the heart to untangle her from it and clip it into position.

Finally, as proof that tuberculosis is taking over my life… I had a bad dream the other day that all my sputum samples were inadequate. Tests for tuberculosis have to be sputum coughed up from the lungs rather than saliva from the mouth. I have a constant battle with my patients to collect useful sputum samples, rather than saliva. This now apparently haunts my dreams.