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.

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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.

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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.

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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.

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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.

 

 

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.IMG_9139

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.

‘Those two are stupid, don’t bring them back.’

‘Those two are stupid, don’t bring them back’ was the greeting I received from the paediatric nurse looking after 8 and 11 year old siblings I had admitted to hospital for tests for tuberculosis.

I’ve just finished my first month working as a doctor in the rural east of Namibia. I live in a village in the Kalahari desert called Epukiro Pos 3 (all the villages around here are referred to by numbers due to the length of their real names – my village is actually Omawewozonyanda and others are even longer) . For the next year I’m one of the two doctors providing healthcare for the San Bushmen tribe in the region. As in the first paragraph, two of the main problems facing the San here are tuberculosis and racism.

The San bushmen are one of the oldest tribes in Africa and are famous for their ancient rock carvings and rock engravings. Their traditional skills as hunter gatherers in the Kalahari desert are no longer valued and in my area they are now the poorest of the rural poor. Their poverty, overcrowded shacks, malnutrition and lack of access to healthcare means they have one of the highest rates of tuberculosis in the world. They are also disenfranchised from mainstream Namibian society and are the only ethnic group to have worse economic and health outcomes than before independence 25 years ago. Racism against them is rife.IMG_5300

The work I’m doing is a mix of clinical tuberculosis work, tuberculosis research, primary care at the clinic, and outreach sessions into the desert.

I diagnosed a family with TB a few weeks ago and they came for a review this week. They were all doing well clinically but I asked them how they got to our clinic: they had set off on Sunday morning and walked a long distance down a sand track with their 4 year old son in tow. They tried to hitchhike to the clinic on the Sunday but couldn’t get a lift so slept by the side of the road in the -4 degree overnight temperature. Finally someone stopped for them late morning on Monday and took them the hour long drive to our clinic. I reviewed them, gave them their medication, gave them some food, updated all our records and watched them set off for the same journey back again. The positive feelings from their improved medical condition were reduced, thinking of the disaster of a journey they will have to continue to make to stay well.

There have been super fun parts in my first few weeks. A Saturday morning watching the district ‘cultural dancing’ competition was incredible. Each of the different tribes from the local schools dressed up in their traditional costumes and performed the dances from their culture. The San groups were amazing and won two of the three age categories. My personal highlight was one of the older San groups performing the most famous scene from ‘The Gods Must Be Crazy’. (An entertaining slapstick comedy film involving the San bushmen, with some of the old guys from my village knowing the San actors in it). I also loved the Namibian equivalent of a naked streaker, which was an 8 year old boy running across the back of the ‘stage’ desperately trying to grab hold of his donkey again.

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My village is pretty rural, 150km from the nearest town and hospital, but there are even more rural areas. Every week we have outreach days further out into the Kalahari desert. Last week we were in a place called Donkebos, 3 hours drive away with the last hour via a deep sand track. We saw about 40 patients in the few hours we stayed there but my absolute favourite was a patient’s husband.

He was about 60 years old and gigantic for a San at about 5 foot 10. He was busy using a solar powered hand drill to make holes in small pieces of ostrich shell for his wife to make into jewellery. I saw that he had a home made bow and arrow next to him and was totally amazed. The traditional San hunters don’t exist in the area close to me due to previous overhunting of animals, laws requiring permits for bow and arrow hunting, and general loss of skills due to more westernised lifestyles.

I asked our translator questions for him and he said that hunts alone most weeks,(he doesn’t trust anyone else to be silent enough), tracking antelope such as springbok or kudu. He showed me his bow + arrows and the snares he had for catching smaller animals. Meeting him was a highlight of my week and a reminder of the traditional life that I had read about but not seen. DSCF0713

Life is different in Epukiro. The hostels attached to each primary school are for children to stay in if they come from a distant village. We were driving back from the local town and saw a collection of young San children walking along the road. We recognised one of our young patients and stopped. He told us they were walking home as it was a weekend the school hostel was closed. They had walked 15km already and had about another 15km left to go to get to their collection of villages. They were between 6 and 11 years old. We had 41 children in the back of our ambulance (about 2/3 of the size of a British ambulance) on the first trip, and then had to go back to pick up the other 43.
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I hope writing this blog semi-regularly will give friends and family some idea of what I’m doing over the next year.