Against the odds in southern Africa

The plane touched down through the haze of a midday winter's sun in Windhoek, Namibia. Here I was, a fourth-year medical student with stethoscope in tow - enthusiastic and blindly optimistic, but ready for my adventure in southwest Africa.
 
My long journey onwards, north, from Windhoek took two full days, along dusty roads and through arid landscapes. I eventually reached my home and place of work for the following seven weeks. Ondangwa.

Some 540km north of the capital, the town is situated close to the Angolan border and lies in a dry, barely populated land of two tribes; the Owambos and Himbas. The majority of the population are subsistence farmers, living on small farms in huts of little more than four walls and tin roofs. Surviving in the second-most sparsely populated country in the world means toiling for a living through infertile, dry land with hundreds of miles between homes and to the nearest services1.

Surviving on charity

The hospital I was to work in, known as Onandjokwe Lutheran Hospital, is set just outside Ondangwa in dilapidated barracks within a sandy backdrop of trees and bush. Originally an old Lutheran missionary hospital opened in 1908, it now survives through minimal state support and continuous charitable funding through the Lutheran Medical Service (LMS). The hospital serves 250,000 people across the north of the country with 460 beds and an outpatient department treating 400 patients daily. With only 15 doctors, the hospital is well under its 40-doctor target.

After the journey from Windhoek, my surroundings had changed somewhat inconceivably. Leaving the pre-colonial Germanic city, Africa soon came into focus. In Ondangwa, gone were the street lights, as were the chain stores and cosmopolitan vibe, replaced by free-grazing animals, market stalls and "bottle stores" (Namibia's answer to the "local"). It was quite a culture shock, in contrast with my entrance into the hospital with its whitewashed exterior, new signs and paved entrance; all giving quite the positive first impression.

Once I was settled into my basic accommodation I was given a tour around the hospital site, soon to have my first impressions proven wrong. Behind the whitewashed facade, the wards were interconnected with open, tin-covered walkways set in barren patches of sandy ground. These cracked walkways connected the separate barracks, all needing attention from either subsided walls to broken windows.

This would be my home for the following seven weeks, working around the site in anaesthetics, general surgery and general medicine. Starting work with the anaesthetists, I entered the theatres for my first experience of African medicine.

HIV and a needle-stick injury

The theatres were superficially similar to those I'd seen before. However, after changing into tattered green and white cotton scrubs, the theatre looked somewhat different; a single strip-light hung above two dim theatre lamps with flies buzzing overhead and equipment well past its prime.

On my first day, I witnessed a caesarean section on a known HIV positive primigravida woman. The process was as anywhere else in the world, albeit for the cost-effective superseded drugs. The operation was going smoothly from initial incision to delivery of the newborn and to closing. However, as the obstetrician was suturing, the surgical assistant slipped, causing a needle-stick injury to the surgeon. Pulling her hands from the patient, looking visibly shocked she removed her glove and bled the finger while rinsing with surgical spirit.

Soon after the event the obstetrician was placed on post-exposure prophylaxis placing her in the most invidious of positions; waiting three months for a negative HIV test result.
 
This occurrence happens all too often in Namibia. With 21.3 per cent of the population living with HIV, the spread and prevention of the disease is of paramount importance to the nation. The Namibian government is attempting the daunting task of HIV prevention and treatment, spending more than $25m a year on HIV/AIDS2. USAID published a paper in 2001 which showed that over 75 per cent of hospitalisations were due to AIDS-related illnesses while it accounted for 50 per cent of deaths among individuals aged 15-493.

Throughout my time an Onandjokwe hospital, the sheer number of patients who I saw with HIV was shocking, but for the population as a whole this was only the tip of the iceberg, as many from the surrounding rural areas have never even taken a HIV test. Because of this, the precautions which had to be taken during at-risk procedures were always paramount, an important learning experience when facing an ever more flippant attitude to infection control in UK.

A life expectancy of 42

 In 2002, the country's life expectancy at birth had dropped to just 42, down over 15 years from 1990. This led to the Namibian government rolling out a free antiretroviral treatment (ART) campaign for HIV, supported by USAID and UNAIDS. By 2005, the scheme produced a three-year increase in the life expectancy of the average Namibian2.

Following my work in the general medicine department I soon saw the drawbacks of the ART available. With limited resources the hospital relies on much older ARTs, so when the limited first-line therapy fails to raise a patient's CD4 count, there are few other options available. Along with this, the much older drugs which are accessible, cause many unwanted side effects such as bone marrow suppression, nausea and vomiting. But with few other options, these effects are often treated in their own right.

Education campaign

The government, along with USAID, UNAIDS and others, are continuing the fight in HIV prevention. Through education of the younger population, it is hoped to increase abstinence into later years, to encourage longer relationships and to promote the widespread use of condoms. It is also hoped to dispel the stigma attached to HIV & AIDS.

Along with this it is hoped that the population will be more willing to take the programme's free voluntary counselling and testing. It is hoped that once individuals know their HIV status (whether negative or positive) they will take steps to change their behaviour to avoid infection3. Financial support for the projects is evident throughout the hospital.

Free male circumcision

Another of the key schemes laid out by Namibia's department of health is the promotion of male circumcision to stem the spread of HIV. Based on the 2005 IAS conference which reported that male circumcision can reduce female-to-male transmission by up to 75 per cent, it was decided to publicise and make available free male circumcision throughout the country4. The scheme hoped to stem the spread of HIV through the main source of transmission: heterosexual intercourse. It brought about a massive increase in the workload for the general surgeons with at least one circumcision on the theatre lists daily.

A large problem, with the introduction of this scheme, however, is the poor health education given to the locals before and after the operation. Although they are still educated about the importance of using protection during sexual intercourse, young circumcised men often saw themselves as almost impervious to HIV. It might be argued that an increase in at-risk sexual activity which could occur because of the altered behaviour of those circumcised negated the premise of the scheme.

Tuberculosis admissions

Along with the colossal numbers of patients I witnessed with HIV, tuberculosis (TB) was also a huge problem in Namibia. Acting synergistically with HIV, TB was often seen in patients with pre-existing HIV/AIDS, with the WHO quoting that around 38 per cent had pre-existing HIV.
 
As with HIV, treatment for TB is available, albeit the cheapest option. With a 0.76 per cent yearly incidence rate, there were many admissions to Onandjokwe hospital and while there I saw both the successes and failures in TB treatment. An ever increasing number of patients with TB had multi-drug resistant strains5.

This is a steadily growing trend with the TB ward struggling to cope with those requiring in-patient treatment. It was the largest ward in the hospital and upon your approach the desperation is apparent; from the emaciated patients' gazes from behind the wire fence to those confined to their beds the atmosphere was truly forlorn. Although the medics and surgeons tried their utmost to help such patients through what little was available, ultimately many passed away.
 
Though the staff at Ondangwa work in difficult circumstances, they showed commitment and dedication. As the surgeon I worked with said: "Some treatment is better than none at all."

In retrospect, I feel he was correct. Many woud impose a westernised ideal of medicine upon a developing nation but if things are put in perspective, Namibia has relatively good access to healthcare of which the quality is superior to that of the rest of sub-Saharan Africa.

References

  1. Namibia. Britannica Encyclopaedia 2007. 07/07/2008 [www.britannica.com/EBchecked/topic/402283/Namibia]
  2. Report on the Global AIDS Epidemic. UNAIDS Publication. July 2004.
  3. Namibia Report. USAID Publication 2008. 10/07/2008 [http://www.usaid.gov/na/overview.htm]
  4. Auvert B et al. Impact of male circumcision on the female-to-male transmission of HIV. IAS Conference on HIV Pathogenesis and treatment, Rio de Janeiro 2005. TUOA0402.
  5. Namibia TB Key Indicators 2006. WHO Report. 15/07/2008

This guidance was correct at publication 24/04/2009. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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