This week in the office there was a 5 day training for the Indoor Residual Spraying (IRS) part of the study. This has been a bit delayed in being rolled out because there were some procurement issues with the insecticide we are using and staff hiring delays as well. But better late than never! We hired a new Spray Assistant last week and are in the process of trying to hire someone to replace our current Spray Coordinator because he is clearly not up to the job (but that’s a completely different story).

Since we are so short-staffed, we really wanted to have the two drivers attend the training so they could help and fill in when necessary. But if they were out for the week, that meant that no one would be available to drive the teams out to the field to continue the case investigations. After much debate, Kate and I decided that it was a priority to have the drivers attend the training so we made a lot of changes to the normal schedule. One of our field investigators has a driver’s license so we convinced him to drive himself and the study nurse for a week. Then we got a driver from another team to join our camping team for the week, but that meant that the other team needed a driver. I agreed to drive that team three days that week, while Oliver would drive them one day (he’s supervising one of the studies that they are working on anyway), and Davis, the UNAM boss from Windhoek who would be in Katima for the training, would drive them one day.

I knew that this team worked longer hours because I would not see them in the office when I was leaving at 5:30 or 6 pm, but I underestimated how long some of their days were!

The team I agreed to drive is working on a project called MERFAT. It is a horrible acronym but a pretty interesting project. They are hoping to identify risk factors for getting malaria in the local population by interviewing people who have been diagnosed with malaria and people who come to the clinic, have a malaria test done but are shown to be negative. The study was supposed to finish in March, but with the outbreak that has been occurring they decided to extend it to see if the risk factors have changed between the two settings. They are working with cases from 5 of the 11 health clinics in the area, but a few of the clinics are over 100 km from the office, so this is a very resource intensive project.

The interviews are being conducted at people’s homes (or wherever we find them), so each person is found individually and sometimes they live very far from the health facility. Ultimately it means a lot of time in the car and a lot of driving!

Mondays are always a bit hectic with the staff meeting first thing, then having all of the teams in the small office getting packed and out the door, but this week was even harder because there was all of that plus our admin assistant was on vacation so I had to do her job of giving everyone their airtime and money for fuel, plus making sure that the training was starting and that Davis was getting picked up at the airport. It was a crazy few hours but I finally left with the MERFAT team and we headed off to the clinics. We visited two of the closer ones that day so it took less than an hour to get to the first clinic. However, from there it got tougher.

There are only a few paved roads in the area so once you leave the main pathways everything is dirt. Some of the dirt roads are very good and you can drive 90-100 km/hour on them, but others are like driving along a sandy beach except that you are trying to follow two narrow tire tracks so you don’t accidentally drive over someone’s crops and have them get mad at you. And sometimes the sand is so deep that if you stop for a moment to ask someone for directions, you get stuck and stall the vehicle. Several times. Until you remember to engage the four wheel drive. And even then you might stall again until you reverse a bit and then go forward at speed. These are just a few of the fun experiences I had.

If all goes well, the Research Assistant, Abigail, goes to a clinic and collects a few forms and DBS cards from the cases and controls the clinic nurse saw that week. The form has the patient’s name, age, and phone number so ideally Abigail call them, tells them about the study and makes an appointment to interview them at their home. Abigail is from the area and knows where most of the (unsigned, small) villages are located, so once you contact the person, you can (in the perfect world) drive there and find them at home to interview.

Of course, there are always challenges to what, on paper, sounds easy. For example, sometimes the patient gives the wrong phone number. Or their phone is just off because it has run out of battery and they don’t have electricity to charge it. Or there is no network so you can’t call. Or you drive to the village, talk to someone and find out that the person you are looking for has moved. There are also several villages that go by the same name, so you might have the right village name, but wrong location. Also, people here go by multiple names: everyone has a Christian name, a traditional name, several nicknames, and sometimes several surnames. Not everyone knows all of one person’s name so you might ask someone in the village for “Precious” but she only goes by Precious at work; in the village she’s known as “Mathilda” so the person you talk to says they don’t know Precious, when really they do. Children are the hardest to find because people in the village might not know their name and of course, a lot of children get malaria.

All of this would be easy if there were addresses, but those don’t exist in these rural areas, so you have to do a lot of sleuthing.  Which means more time driving. It’s really exhausting work, driving everywhere. On the paved roads you have to really watch for cattle, goats, and dogs in the road, as well as other cars. On the dirt roads, you have to watch out for animals, people walking and cycling, as well as holes, bumps, dips, and other blockages.

Once we found a person and confirmed their identity, Abigail would conduct a 20 minute interview then we would go on to the next person. I tried to be productive in those 20 minutes by reading papers on my laptop, but it wasn’t great. I did get some things done while waiting around, but I would have been much more productive in the office.

Abigail lives just outside of town and it’s difficult to get a taxi from the office back home after 5 pm, and she always works after 5 pm, so I dropped her off at home on the way back, then dropped the study nurse near her house as well. But someone had to go back to the office to put the DBS cards in the freezer and unload the supplies, and guess who that was!

On Monday and Tuesday I got back to the office at 7 pm, then went home and checked my email for the first time that day and had to work for another few hours responding to things and following up with stuff.

I was supposed to get a break on Wednesday when Davis was going to drive Abigail and the nurse, but he scheduled some meetings at the Ministry of Health for that day so I was at it again.

I had a day in the office on Thursday which was a nice break from the field and was amazingly productive. I even got home when it was still light out which was a nice treat.

On Friday, I was back in the field on the far side of the region in which we work. Our first stop was Sesheke Clinic. While Abigail was going through her paperwork, a man came in carrying a young boy on his back. The child, his son, was so ill that he could not even stand up. An RDT test confirmed that he had malaria and it was a very severe case. This boy immediately became a top priority for the nurse on duty because he looked like it was going to die.

Sesheke has a catchment population of around 3,500 people. Typically there are two nurses at the clinic. This week one of the nurses was at a week long training in town so there was only one nurse. The two other next closest clinics only have one nurse each and both of them were also at the training so people were coming from even further afield to get treated here. Imagine living somewhere with 8,000 people and one nurse. There are no doctors for over 100 km and don’t own a vehicle and you can’t afford transport that far. It should be unbelievable, but this is what life is like for much of the world.

The deathly ill child was so sick that he was having convulsions. The first line treatment for severe malaria like this is to give IV artusunate, but the child was thrashing around so much that the nurse could not get the IV in his arm. Since our team has a nurse with us to test anyone who is sick at a household where we are doing an interview, the clinic nurse requested the help of our study nurse in placing the IV. The two nurses worked together while to men held the child down and finally managed to get the IV in and start treatment. The boy’s breath was quick and shallow and his eyes glassy.

In the meantime, a van came in and several people helped a young woman out and into the triage area. She was so sick that she could hardly stand either. She was quickly diagnosed with malaria as well.

The young boy absolutely needed to go to the hospital and the young woman probably did as well. The closest hospital is in Katima, 110 km away. They have 4 ambulances for the entire region. When the clinic nurse tried to call the ambulance driver, he didn’t answer his phone.

Abigail and I quickly decided that we couldn’t leave until we were positive that the boy would get to the hospital. The nurse tried calling several people at the hospital to see about the ambulance then ran out of airtime, so we let her use our phone. She finally reached someone who was able to track down the ambulance driver in person and send him to us. Even when we were told the ambulance was coming, we decided to wait because sometimes they stop to pick up other patients along the way and might not arrive for 4 or 5 hours. This child wouldn’t survive that long and I was ready to put a mattress in the back of our truck and drive him to the hospital myself if need be.

Fortunately, the ambulance arrived in about an hour, which is pretty fast considering the distance traveled, and the boy was taken to the hospital with his father. By that time the young woman had also been treated and was doing a bit better so it was decided that she didn’t need to go but would be observed at the clinic for a while.

Once the emergency was over, the clinic nurse was so grateful for our help. She thanked each of us heartily and called us all angels because we came in her hour of need. She couldn’t have gotten the IV in by herself and even thanked me for bringing the nurse to her. I just wished I had been able to do more. Rarely have I felt so helpless.

It was an intense three hours but I think it has a good ending for those patients, at least. During that time three other malaria cases were also diagnosed but they were not as serious and were sent home with treatment. This outbreak is still out of control and seeing it first hand like that hit home in ways it had not before. Even in town where we get reports of the number of cases it doesn’t seem as dire or as urgent somehow. But when you are at the clinic, potentially watching a kid die, or interviewing the mother of a case who has gotten malaria for the second time in two weeks, it completely changes your perspective on the situation.

This week we’ve also gotten word that several of the clinics are running out of ACTs, the primary treatment for uncomplicated malaria. The clinics get their stocks from the Central Medical Supply at the hospital and when Kate and I went there last week, they only had a few boxes of treatment left and didn’t have enough to resupply the clinics who were almost stocked out. We gave what stock we could to two clinics, but our supplies are not very great. If more medicine does not arrive soon, the situation will quickly go from bad to worse.

There have already been a few deaths from malaria in recent weeks, which should absolutely not happen since it’s so easy to treat this disease, but because money and access is such a big factor, people often wait to seek treatment until they are very ill and have been so for weeks. Sadly, then it could be too late.

Luckily, the young boy that we helped got to the hospital that day and will hopefully recover but who knows what long-term consequences he might have because of this.

Situations like these always put things into perspective for me and make me grateful for all of the advantages that I have based purely on where I was born. But it also makes me angry that anyone in this world today has to live like this. Every life should be valued the same and should have equal access to the necessities of life. I like to think that the work I do helps to bring some more equality to the world, even if it is on a very small scale; that’s why I entered the public health field. Although research doesn’t often equate to immediate effects, I think today I made a difference.

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Birthday cruise

I wish I could start every work week on Tuesday. That one fewer day of work really makes a difference. You get to Wednesday so much faster and then it’s all down hill from there. Sometimes just getting through Wednesday, even when you start on Tuesday, seems like a challenge.

We have our staff meeting first thing Monday morning but this week it was on Tuesday. During the meeting each team gives a short report of the previous week and we discuss challenges and other office business. The team started a rapid reporting system for malaria cases last year which is being piloted here for a national roll-out in the near future. Every nurse at each clinic in the area was trained on how to enter information about each new malaria case that comes in to the clinic into a cloud-based system on a tablet and upload those reports each day. We really want this rapid reporting system to succeed, so a team member has been doing a supervision at each clinic (11 total) once a month to compare the paper reports to the online ones and check on any issues and problems.

Our office is extremely short-staffed right now and the only person who is not in the field nearly every day is Ricky. Ricky was originally hired as the Research Manager, the role that I am currently filling in for, but it very quickly became apparent that he was not up to the task of managing such a large study. He got demoted to Reactive Vector Control Coordinator, but since that part of the study has been slow to get started (due to issues of importing the insecticide into the country), Ricky has been doing other jobs, including the supervision visits.

On Tuesday he reported that one clinic, Sachona, was not using their tablet to send information about their malaria cases. When I asked him why not, he said it wasn’t working. When I further probed to see what the problem was, he revealed that he hadn’t even asked to see the tablet, he just took the nurses word that it was broken and did nothing about it! It could have just been out of battery power, or data, but he didn’t even try to troubleshoot the problem and for nearly a week Sachona’s cases weren’t being reported.

There was nothing that Kate and I could do at that moment because there were interviews on Tuesday morning and I had a long list of other things to get done. But instead of going out with our teams on Wednesday, we had to go back to Sachona, 110 km from Katima, with Ricky to figure out what the issue really was.

No wonder I can never catch up on my to-do lists: I am constantly distracted by other problems that arise every day.

The good news of the week is that we had one outstanding candidate for the new Spray Assistant position, which is a good thing, because the training for the job starts next week!

Tuesday flew by in a whirlwind and it was 5:30 before I knew it. Oliver, Kate, and I headed to Kate’s place for our weekly Senior Management Team (SMT) call with the folks in SF and I cooked us a good dinner while listening in and giving my two cents worth.

It is always nice to share a meal with others and to unwind at the end of a long, busy day over good food. We all complained about work a bit and gossiped about our co-workers, and generally had a pleasant evening.

On Wednesday while Oliver was out with his serology team members, Kate and I drove out with Ricky to switch vehicles with the camping team, then went to Sachona to look at the tablet. There’s a large crack in the screen which makes it nearly impossible to use, so now we have to find a new tablet somewhere. I spent most of the morning in the car, driving around. Then in the afternoon, Kate and I drove around town, trying to find a store that sells a good tablet and to buy other things for the office. I swear I spend 25% of my time here just buying things. Good thing I got a travel advance before I left!

The three of us (Kate, Oliver, and I) gathered at Kate’s for dinner again on Wednesday and I made a veggie curry with chickpeas. Oliver joked that he already had his two best meals in Katima in his first three nights there. That made me smile.

Thursday was March 31, and my birthday. Kate found out about it a week ago and planned an evening river cruise for me. We left work at 4:30 and made it to the dock at the Protea hotel by 5 where our river boat was awaiting us. We were joined by one other passenger from South Africa and we motored upstream for an hour, enjoying the evening and talking about non-work related matters. We passed a place locally known as “hippo island” and saw a few heads sticking up out of the water. As we approached, they disappeared one-by-one until only two sets of ears remained visible.

It gets dark here around 7 pm so after an hour and a half we turned around and headed back. We saw a flock of bee-eaters at their nests on a sandbank and got a close view before they flew away. I wish I had remembered my binoculars.

I got to view another spectacular sun set over the Zambezi river, and this time I shared it with others. For pictures of the evening see here: Birthday cruise

We were each supplied with a bottle of water and a beer/cider along with caramel corn, peanuts and some crackers and we supplemented our snacks with grapes, dates, cookies, and white wine. By the time the cruise was over I had eaten enough that I wasn’t very hungry for dinner. We went to one of the two restaurants anyway and I had a bowl of butternut squash soup. Kate insisted that we get dessert so the three of us shared a piece of carrot cake and flan. It wasn’t very carroty and the icing was lemon flavored, but it was tasty. There was no singing or candles, but it was a great evening and I’m very happy with my celebration.


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Chobe self drive

During my previous weekend in Kasane, I had seen several private vehicles driving in Chobe National Park, on the dirt roads and not just the paved road I had driven on to get to Kasane. It seemed like a cool thing to do, so as I came into town on Friday, I stopped at the park entrance and asked about it. I was told that as long as you are driving a 4×4, you can buy a day pass for P50 for the vehicle plus P120 per person (that’s about $15 for a single person). Since nearly all of the guided tours drive the same two or three loops in the park, I thought I would try it out for myself.

On Sunday morning I got up at 5:30 and packed a few snacks and water for the morning and was at the park gate just after they opened. I got a lot of strange looks from both drivers and passengers as I took my truck through the gate, but I think they were just jealous since they weren’t doing it themselves. At first I just followed some of the game drive trucks, but I went at my own pace and stopped to watch the sun rise over the river and watch some hippos floating nearby. I passed some tours as they took pictures of impala (been there, done that) and went searching for some more interesting animals. Of course I saw many elephants; it is what the park is known for. But I decided to not stop at the ones far away and instead keep searching for elephants close to the road. I was not disappointed. I encountered several herds that were crossing the dirt roads and got some great pictures of them and some babies.

See the best of pics here: Chobe drive

I also got some great views of African fish eagles, giraffes, buffalo, and some smaller birds moving too quickly for my camera.

Some sections of road are very sandy and I got stuck once, until a driver passed me and reminded me to engage my 4-wheel drive. That really helped to get traction and I used it a few times in sand and on steep hills. I only stalled twice, which I consider a win for the morning.

I saw the American girls and British family from the day before on their own safaris. I think they did double-takes when they saw me. After about three hours I was tired of sitting and driving, so I drove back to the lodge and had a proper breakfast. I then spent some time trying to get a few work related things done before giving up on the super slow internet and just reading instead.

In the afternoon I went back in the park and drove around some more. I tried exploring a different area away from the river, thinking that some animals would be at a watering hole I found, but alas, there is too much water in the area for anything to be tempted there. Also the grass is really high right now so it is very difficult to see anything.

Overall, it was a lot of sitting on Sunday and at times I had to pay more attention to where I was driving than my surroundings so after a two hour afternoon game drive I called it and headed back. It was happy hour when I got back so I enjoyed a cocktail on the patio and watched the sun set over Africa.

The Safari Lodge only has buffet meals, which I knew I would eat too much at, so for dinner than night I walked next door to the Chobe Bush lodge (owned and operated by the same people) and had an ala carte fish dinner with mashed potatoes and veggies. Other than eating every meal alone and missing Jacob a lot, it was a lovely weekend and was over far too soon.

My drive back to Katima on Monday morning was uneventful and sadly, did not include any animal sightings. I had to move accommodation because I had been staying at Kate’s flat the previous week but she was coming up for the week interview candidates for the new spray assistant position so when I got back to town I packed up my belongings and transferred them to my new B&B, the 3 Palms. Then I had to rush to the airport to pick up Kate, Mukosha, Dr. Bock (from the UNAM main campus in Windhoek, here for the interviews), and Oliver, a clinical fellow at UCSF who is heading the serology sub-study in Namibia. The afternoon flew by with dropping people off, getting settled in the new place, and catching up on dozens of emails.

Even though I don’t celebrate any religious holidays, it was a happy Easter and I enjoyed every minute of it.

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Victoria Falls

On Saturday morning I got picked up at 8:30 for a day trip to Vic Falls. A 15 passenger van came and I think everyone who was staying at the lodge the previous night climbed aboard for the trip over the border. At the border crossing I talked to two American women who are medical residents and were working in Gaborone, Botswana for a month. They didn’t know what they were going to do for the day except walk through the national park and go souvenir shopping so they didn’t seem like likely companions for the day.

I really wanted to take a helicopter ride over the falls so I could compare it to the last time I was there in December 2011. December is the end of the dry season and large portions of the falls were not even flowing then, whereas we are now in the middle of the wet season so I was expecting a completely different experience.

Our driver dropped me and a British family off in town where we could book our activities then took the others to the National Park. The family had two small boys who wanted to go zip-lining from the bridge but the tour operator said they were too young (10 and 11) and were not allowed. After much back and forth between the parents and grandfather, they decided to join me on the helicopter ride so the 6 of us were shortly picked up and transferred to helipad.

After a short briefing and being weighed, our pilot landed and we were taken to our aircraft. I learned my lesson from last time and made sure I was the first person heading toward the helicopter, because that person gets to sit in the front, next to the pilot. We were strapped in and a few minutes later we were airborne!

I cannot possibly describe the wonder and majesty that is Victory Falls. Words simply fail me, so I’ll let you try to imagine it by looking at these pictures: Victoria Falls

We made several passes over the falls and then went 4 km upstream to see all of the water that flows into it. The 13 minute ride was over in a heartbeat but the memories will last forever. It was an incredible experience and I’m so glad that I went.

The falls were completely different than the last time I was there: the amount of water flowing was staggering and nearly incomprehensible.

After the ride, we were made to watch a video of ourselves with some stock footage put in. You could buy the video and still photos on DVD for $50 USD. I declined, preferring to savor the memories. Then we were taken back into town where our driver was waiting for us. He transferred us to Victoria Falls National Park and the very nice British family invited me to have lunch with them. I ended up spending the rest of the day with John (the grandfather), Steve (father), Lindsay (mother), Ed (older boy), and Nick (younger boy). They were lovely to talk to. Steve works for BMW and he and his family are currently living in Dubai, after having spent a three years in northern China, then 18 months in the UK. John lives in the UK but has a business in South Africa and thus travels to the area several times a year. They had just arrived for a two week holiday and the boys were very excited.

With a quick lunch to tide us over, we went walking through the national park. Everyone we saw coming out was completely drenched with water and at first it seemed very bizarre because as we went from view point to view point, we got a bit wet with mist but nothing too bad. The power of the falls was even more striking up close. I can’t even imagine the volume of water that was rushing by with each second. See the album above for more pics.

We were walking along in a fine mist when suddenly we made a slight jog over and were in a proper rain shower. Except that this was not water from a cloud above, but river water falling after being sprayed hundreds of feet in the air due to its impact at the bottom of the gorge. In an instant we were completely soaked! I put away my camera then for safe keeping, but you couldn’t see more than 10 feet ahead of you so there was no point in taking pictures anyway. I could feel the sun beating down and it’s probably the only time in my life when I felt like I was going to get sunburned while in a rain shower. It was over 90 degrees F out so being wet actually felt really good. And we dried very quickly.

After the park tour we went to the Stanley Hotel, which is over 100 years old and was built when the British were erecting the bridge between Zimbabwe and Zambia. John and I got a drink while Steve found a different tour operator who would allow the kids to go zip-lining. They headed off while and John and I relaxed and enjoyed the view. I toured the stone sculpture garden and got some pictures of the bridge. The rest of our bus showed up shortly and the American girls joined us at our table. We decided to get high tea since it seemed apropos and we enjoyed our tea with scones, jam, cream, and some cakes and finger sandwiches. Very British.

By that time it was after 5 pm and everyone was tired. Plus, we had to get back to Botswana before the border posts closed for the night, so we packed everything up and headed back. It was an amazing day and I have some wonderful memories that will last a life time. My only wish was that Jacob could have been there to share it with.

I was a bit sad to move accommodation that night because it would have been nice to chat with my acquaintances over dinner, but it was dark by the time we got back and I wanted to drive to the Safari Lodge before it was too late. I was even more keenly aware of my loneliness when I checked into my room which was on the second floor, overlooking the river and looked exactly like a honeymoon suite, with a king bed, large tub, and all. Perhaps the next time Jacob will be with me.

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Kasane again

I had a short week at work from March 22-24 because both Monday and Friday were holidays. I thought with an extra day off the staff would be energized for the week, but I was wrong. Perhaps they were just trying to get through the days until they had a 4 day weekend. I know I was.

I wanted to spend the long weekend at Vic Falls in Zimbabwe, but it was not possible to take the rental truck into Zim so then I thought of staying in Livingstone, Zambia which is right on the border of Botswana, Namibia, and Zimbabwe, but after checking the rental agreement, I could not take the rental car into Zambia either. I’m not positive about the exact reason for these rules, but I think it has to do with trying to import the car illegally or trying to sell it for spare parts. Anyway, after hours of searching different options, including having a tour company drive me to Vic Falls (too expensive since I was just one person), I finally decided to drive back to Kasane, Botswana and stay there then take a day trip to Vic Falls with a more local tour agency.

On Friday morning I slept in then headed out for a new adventure. When I got to the Ngoma bridge at the Namibia/Botswana border, I was amazed at how much had changed in less than a week: the river was much higher now and was flowing throughout the channel instead of just in a few rivulets. I saw a herd of elephants on the far side of the river bank, drinking and splashing around. I will never get tired of seeing these amazing animals.

After going through immigration on both sides (and having to go back because the woman on the Namibia side failed to actually stamp my passport), I entered Chobe National Park again. Within a few minutes of driving I saw a lone bull elephant on the side of the road, seemingly there to greet me. I stopped for a few photos before driving on. In just a short way I saw two greater kudu on the edge of the woods as well. Luck was with me today!

Most of the photos are too large to upload here, so you can find an album here: Kasane 25 March 2016.

I had to stay at a different place than the week before because a lot of accommodation was booked for the holiday weekend, so I decided to spend one night at a place on the edge of town called Kubu lodge, then treat myself to two nights at the Chobe Safari Lodge, which is very upscale and posh.

When I got to Kubu I was pleasantly surprised with the facilities. I had my own cottage on stilts right near the water. Although it did not have A/C, it had a wonderful king bed with canopy and bed net and a deck with chairs to enjoy the view. I declined the river cruise that the lodge had that afternoon and decided to check out a wildlife sanctuary along the river. This new park opened just a year ago and had a 2 km walking path along the river where you could look out. I saw a few warthogs taking a mud bath and signs warning me about crocs and hippos but the river is pretty swift in the area and I didn’t see any other wildlife, except for a few birds. The park contains a very small hill which I climbed for a slightly elevated view of the area. The hill is probably less than 50 feet high but I got slightly winded hiking to the top since I’m now so used to extreme flatness. I also tried exploring the traditional building they had on site but they were occupied by a bunch of baboons and I was not willing to risk a close encounter with their sharp fangs in order to see the buildings up close.

After a few hours I returned to Kubu Lodge and walked their nature paths, looking for some animals. I had seen a bushbuck on the property earlier and was hoping to see more, but all I saw (or rather heard) was flies. The flies were relentless and made the walk sort of miserable, but I finished nonetheless.

For dinner I decided to try the fixed menu at the lodge instead of driving into town at dark. It was one of the best decisions I have made in a long time! Dinner was amazing. It was a four course meal with carrot ginger lemongrass soup, mushroom souffle, your choice of entree (I got the fish), and dessert (pecan pie or chocolate cake). Each course was exquisite and presented well. The portions were a good size and I was very full and happy at the end of the night.

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On Saturday morning, I packed up the Hilux and hit the road for Botswana! With Monday off, I decided to spend the long weekend in Kasane, Botswana, which is just over the border and right next to Chobe National Park. Jacob and I spent a few days in Chobe two years ago and it’s definitely worth visiting again as it has over 75,000 elephants (half of the elephants in Botswana) and is right on the Chobe river.

It’s about an hour drive from Katima to the border of Namibia and Botswana. Overland border crossings can be a pain at times. At this one, you park your car in Namibia, go into immigration, fill out a form, then wait in line for the officer to stamp your passport. If you are driving a car, you then have to fill out another form, wait in another line and have that processed. You then drive about 100 yards, park, get out of the car and enter a small booth where you have to sign a paper register asking for your details and the vehicle’s info, including chassis and engine numbers. Then you drive about 200 yards, park in Botswana, enter their immigration office, fill out their form, wait in another line for the passport stamp and another line for the car registration and payment. After about 4 stops, 500 yards of driving, and an hour of your life (plus some money), you are in Botswana. Then you drive a few kilometers and have to stop, get out and register yourself and vehicle as entering Chobe National Park. Somehow I feel like this process could be a bit more streamlined.

Nevertheless, I made it over the border and into Chobe, on my way to Kasane. It took me about 2.5 hours total travel time, which was not bad overall.

Kasane is slightly larger than Katima but not by much. It has an airport and is the jumping off point for several of the parks in the area. There are a few luxury safari lodges on the edge of town because of the proximity to Chobe and a few B&Bs, self-catering guesthouses, two clothing stores, two grocery stores, and a few tourist attractions. I stayed at The Old House B&B and had a lovely room with plants all around and a stream just outside my door.

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I immediately booked a river cruise for that afternoon, then went in search of lunch. The Old House is right on the Chobe River and has it’s own dock and boats. On my tour there was another couple but they didn’t speak much English so it was difficult to communicate. We motored upriver and stopped to register at the park office before entering the park. The river is a great way to see the area and in the afternoon, many boats head out, searching for animals. We were not disappointed!

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We saw several herds of elephants coming down to drink and splash in the water. There are hundreds of hippos in the shallow areas and we got pretty close to a few of them as well. The Chobe river is a bird lover’s paradise and I saw many different species, but none close enough or still enough to photograph.

Meanwhile, on the horizon huge storm clouds started to roll in. An hour into our 3 hour tour the sky got really dark and it started to rain. Then it started to rain harder! As a team we decided to head back and saw that most other boats were doing the same.

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There were ponchos on the boat for everyone, but it rained so hard and there were so many boats speeding back and creating spray that I got completely soaked even through the poncho. It was a warm rain, but I was only wearing a tank top and knee length pants. I wouldn’t say I was exactly cold, but I was not warm. It’s all part of the adventure, right? I mean, it is the rainy season afterall.

When I got back I took a warm shower to get the sand off then went down to the B&B restaurant for dinner and enjoyed Hake, salad, and mushroom soup while reading my book.

On Sunday I had booked a morning game drive and was glad to see the sun shining when I got up at 5:30 am. I was the only one staying there who had booked the morning game drive so I had a private 4×4 and driver! For 3 hours Albert drove me around and related his knowledge about the local flora and fauna. He just started as a guide 3 months ago but had a vast knowledge of plants from his grandfather. Here’s a few of the highlights from the morning (you might have to click on the photo to see the whole thing):

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I also saw kudu, giraffe, hundreds of baboons, and black-backed jackals. It was a great morning of wildlife viewing and ended all too soon.

In the early afternoon I went to Caracal, a wildlife sanctuary that takes in injured animals and cares for them until they can be released back into the wild or transferred somewhere else. They have several dozen snake species in cages that you can see up close, including all of the most venomous snakes from the area and some that were brought in when poachers were caught trying to smuggle them out of Zambia. They also have several owls, parrots, warthogs, an aardvark (that I didn’t get to see because it was in its burrow), and lesser bush babies! The bush babies are tiny; from ear to ear is about the length of my finger.

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Right now they also have a baby baboon who was found alive, trying to nurse from her mother who was killed by poison. The baby was sick when they found her, but has recovered well and is not super playful and curious.

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It was definitely worth the $3.50 entrance fee!

There was rain in the forecast for the afternoon, but at the last minute I decided to risk it and went on another boat cruise. This one was much more successful and I saw more elephants, hundreds of hippos, birds, buffalo, and a few rare sightings like this one:

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This was only the second time I’ve seen a hippo out of the water (the other time was in Kenya in 2003) so I guess my lucky charm worked.

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It was a wonderful evening and once the sun went down a bit it didn’t even feel too hot. But the clouds rolled in again and we headed back to the dock a bit faster than normal to avoid the rain. It just sprinkled a bit on the way back so we only shortened the trip by about 15 minutes. Overall, it was an excellent day all around and I celebrated by going to the one Indian restaurant in town and getting mixed veggie curry!

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Work musings

Last week I gave a short presentation at our weekly staff meeting about bribery. Since the major funding for this project comes from the Novartis Foundation, we have to follow their rules and regulations and they recently developed an official stance on bribery. The main point is: bribery is illegal and you shouldn’t give or receive bribes. This sounded pretty straight forward to me and I wasn’t expecting many questions or much discussion around this point, but I was completely taken aback when the staff bombarded Kate and me with questions. One person asked if giving a piece of candy to a child who just had a finger prick to draw blood for the malaria testing was considered a bribe. I had never thought about this, but she argued that to the child a treat like that is huge and could be coercive. Some staff were very reluctant to sign anything saying that they received the training and agreed to follow the rules (something required of them by the Novartis Foundation).  I talked to Kate about this afterward and she says that the University of Namibia, the employer of all of the local staff, has an unofficial policy that disagrees with the Novartis Foundation policy and that no one wants to be held to a different standard than what is typical in this context. Basically, if you want to get something done here, it’s fairly common to give a small bribe to fast-track paperwork or cut a line. Ultimately, we decided that when the local PI comes up here in a few weeks, we’ll have him go over the rules with the staff because he has more authority than either of us.

According to Kate there are very strict labor laws in Namibia and everyone knows the rules very well. If someone things they are being treated unfairly or are asked to do something that’s not in their contract, they will threaten to quit. That seems like a pretty poor strategy for someone in an area with 50% unemployment, but well-trained people who are qualified for mid- or high-level jobs are in high demand and they feel like they have control of the bargaining. This does not always work out in their favor though: just in this study Kate cited two examples of people demanding double the salary offered or they would quit and they their contracts were not renewed.

The work culture here is different than in the US in other ways as well. Here there is no sense of urgency, ever. No one ever rushes anywhere to get something done. For example, if someone here forgot something in the office and the rest of the team was waiting in the vehicle to depart, that person would not rush to retrieve their forgotten object; they would amble along at their usual pace. In fact, everyone walks very slowly. Part of the reason is that it’s hot and the faster you walk the more you sweat, but it’s more than that. I have trouble walking as slowly as people here; even when I am shuffling along I often outpace the locals.

I’m not really sure what motivates people in their work here. Certainly everyone I know wants the project to succeed and to streamline data collection, but there’s some sort of disconnect in the thought process about how to make that happen. I can’t quite explain it, but it’s sort of like people don’t have a good understanding of how their actions can lead to consequences for themselves or other people.

And when something goes wrong, no one likes to own up to it and take the blame. This is not so different as from the US; no one wants to be called out for doing things incorrectly of course, but somehow it seems different. I don’t know.

I went out to the field with one of the teams on Wednesday and we had an amazing day! The team was ready to go at 8:20 am (a new record). The place we were looking for was only 50 km away so we got to the area in less than 45 min. The first person we talked to knew the index case we were looking for and was able to direct us to the house immediately. We found the case and his mother within moments and she let us set up our interview and testing area in a covered building that serves as her kitchen so we were out of the sun. Most people had their health passports with them and they had the GR IDs we assigned. Nearly everyone in the closest houses were home and we were able to interview and test over 25 people that day as they came home from school or work. We only missed a few people who were away at a funeral. And we got back to the office before 5 pm!

It was the ideal data collection situation and I tried to talk to the team on the way back about what went right and how we can continue this trend in the future. They had some good suggestions and we will see if they can implement them in the future. Here’s hoping! Obviously some things are out of our control: if the index case as moved since we assigned them a GR ID, then it can take a lot of time to track them down and determine if they still live in our study area, but there are things, like having the bins packed with enough supplies for the week, that are in their control that I would like them to improve on.

On Friday, Kate flew back to Windhoek for a week, where she is based. Since January she has been home for one week and has struggled to keep up with the staff there and all of her other job responsibilities. She’ll be back at the end of the month, but until then I am in charge here! Yikes! She left me with what feels like an overwhelming list of things to do, but there’s no expectation to get them all done this week.

Luckily, Monday, March 21 is a holiday. It’s Namibia’s Independence Day and they are celebrating 26 years of self-rule. Can you imagine remembering when your country became independent? It boggles my mind.

Then, Friday, March 25 is Good Friday which is also a national holiday, as is Easter Monday, March 28! That means I have a three day weekend followed by a four day weekend ahead of me! There will probably be some work involved, but I am looking forward to getting out of town.

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I’ve been working so much during the week that I never have the energy to write a blog entry at the end of the day. Plus, I don’t believe that my daily activities warrant a play-by-play description of what I’m doing; I think most people would find it rather boring, because, quite frankly, some of it is. Instead, I’ll just try to recap some things of note and focus on things that I think other people will find interesting.

Last weekend I went running by myself for the first time. On Saturday morning I did an 8 mile run to the Zambian border. It’s kind of crazy to think that I can run to another country from where I am staying. In California, I have to drive at least three hours to get to another state! I didn’t want to try taking pictures of the border post from too close a distance, just in case someone didn’t like it, but here’s a distance shot.

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On my run back, I heard the pounding of feet behind me and saw two guys racing to catch up with me. One of them looked like a legit runner, with track pants and a warm up jacket that had some football (i.e. soccer) team’s logo on it. That guy ran very quickly until he was about 10 yards ahead of me but on the opposite side of the street then he slowed down. Sometimes I don’t understand guy’s egos.

However, the other guy was amazing: he was running in, I kid you not, dress pants, a button-down shirt, vest, and dress shoes!! Fancy dress guy caught up with me but could only keep pace for a few hundred yards before he ran out of breath and stopped. The other guy stayed just ahead of me until we came to the major intersection where he stopped and I kept going.

Katima really only has two major roads. On one road you can either go to Zamiba (4 km away) or Botswana (60 km away). The other road goes through town and features two traffic lights and most of the shops and restaurants. There’s one other paved road on which the hospital lies; other wise the smaller roads in town are dirt and the potholes are getting really bad with all of the rain.

The weekends are pretty quiet here. Most people go to church on Sunday. Almost all of the shops close at 1 pr 2 pm on Saturday and may or may not be open on Sunday. The grocery store is open and you can go to an ATM but otherwise you might be out of luck until Monday. There are no deliveries over the weekend so grocery shopping on Sunday afternoon will have the least selection available.

Everyone gets paid at the end of the month, just like in South Africa, and I’ve already been warned to not try to go to the bank, ATM, or grocery shopping/shopping in general around that time because everything will be packed. Most people live from paycheck to paycheck and when they have money they go and spend it. Apparently, it is not uncommon for someone to run out of money near the end of the month and not have airtime for their phone or have much to eat other than maize meal until they get paid. Even our staff, who are paid well for the area, sometimes share lunches because someone can’t afford to even bring food from home that day.

Namibia has over 300 days of sunshine a year, but don’t let that fool you: those are actually some of the worst days because even when the temperature is only in the 80s or so, the sun is really strong and it always feels a lot hotter. When someone says, “It’s nice weather today” they mean that it is cloudy and will probably rain. I find this funny because it’s the opposite of everywhere else I’ve lived.

The terrain is very flat here and the roads are straight but you have to be careful while driving because you never know when there will be cattle, goats or dogs in the road. Every day when we go out to the field or return, we always have to slow down for at least one of those animals. And sometimes they are not in a hurry to cross.

There’s a sign on the roadside that indicates you should look out for elephants. Kate has seen one right next to the road, not too far from town but I haven’t yet. I keep my eye out and fingers crossed every time though.

Work is pretty hectic during the week and when your in the field there’s no internet access so it can feel overwhelming to get back in the evening, quite tired from the sun and dehydration, then get a few dozen work-related emails. The weekend is a good time to catch up with all of those things though, because there’s not much else going on. I just finished reading an 850 page book that I only started after I left home. Good thing I have another one and my kindle!

Women in the villages where we visit tend to dress more traditionally than men. For women this means a T-shirt or rarely a tank top with a piece of cloth wrapped as a skirt that falls between their calves and ankles. Men wear shorts, jeans, or other pants with T-shirts. Out of respect for the culture, whenever we are in the field, I wear a long skirt or sometimes wrap a sarong around my waist over my pants. Our team shirts are red polos with logos on the front and back. It’s not very flattering attire and even the small polo is far too big for me. It’s hot no matter what so even if I were dressed differently I think I would still be sweating buckets. One day I drank 2.3 liters of water and still didn’t pee for 8 hours.

Since some of the cases we are following up with live 130 km or more away, we started one of the teams camping during the week so they don’t have to drive back and forth every day. This saves a lot of time and money and really takes a load off of the drivers who end up working the longest days. Let me explain what “camping” means in this situation. People do sleep in tents, but they are not what you are probably picturing in your mind: they are heavy canvas dome tents large enough for an average person to stand up in. What I would consider a 4 person tent is considered a 1 or maybe 2 person tent here (in a sparsely populated country, people like their space). They have 4-inch thick foam mats to sleep on and everyone brings their own quilt. The camping team is provided with cooking equipment, a two burner stove, and fuel and they camp at whichever clinic is closest to where they are working. The clinics have electricity so they can charge things, running water and showers, and bathroom facilities. They sometimes bring their own laptops and watch movies in the evenings. One of the nurses also let’s people sleep at her house since she has several spare bedrooms. Plus everyone who camps gets a per diem on top of their usual salary. Overall, it’s not a bad deal and the camping is pretty lux; the only downside is that sometimes it rains and things get damp for a few hours. We have the teams camping from Monday until Friday, but Kate says that on other projects, people would camp for months at a time.

It’s hard to supervise the camping team when they are so far from the office and there is so much else to do every day, which is probably the biggest downside from my end. It is especially difficult now because the third study vehicle (a large Land Rover) has been in Windhoek for routine maintenance and to have a roof rack attached. No one is sure when it will be returned. It is an 8 hour drive from Windhoek to Katima so I’m sure no one at Land Rover really wants to bring the vehicle back up here, but theoretically this barrier should be eliminated at some point.

I finally got added as a driver on the rental study vehicle so now I have access to a car after work and on weekends. It is a Toyota Hilux 4X4 with cap and it is huge! It’s also a manual and the steering wheel is on the right hand side of vehicles here so the first evening driving was bit nerve wracking. It also didn’t help that there was heavy traffic in town (and by heavy traffic I mean there were cars on the road and you might have to wait to pull out of a driveway). But I made it from the office to my B&B without getting lost, stalling, or hitting anything so I consider it successful.

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Two teams

Until this point, the two field teams have been going to the same place each day and investigating the same index case. But now that it’s been a few weeks and they are getting the hang of things, Kate and I decided to send the two teams to different places with one of us supervising each team and see how things go. My team returned to the school to finish testing the kids we didn’t have time for on Wednesday while Kate went with the other team to investigate a new case.

Things were much more orderly at the school and we didn’t have as much students left to test so it was much easier to get a good flow going. I even had a few moments to add some things to my to-do list! At the school alone we tested almost 60 people and identified one with malaria. The nurse prescribed the standard anti-malarial treatment and watched her take the first dose, sending the other doses home with her aunt who also works at the school. It’s a good feeling to know that so many people tested negative (although it’s difficult to say if there are any asymptomatic infections), but it’s such a resource intensive process that I wonder how cost effective it is (luckily there’s an economist on the project who is trying to answer just that question).

We finished at the school in about three hours and closed our first investigation! On the way back to the office we stopped by a village to follow up with a patient who reported an adverse event at a nearby clinic. Senior, one of the nurses, interviewed the woman and offered some advice, but the side effects were already getting better and there wasn’t much else that we could do other than give her a phone number to call in case things got worse.

For the first time that week we were back at the office before 5 pm and everyone was happy to leave work on time. Kate’s team came in a bit later but still before 5:30 so we considered it successful.

After work Kate and I went running and she showed me her usual loop which goes through town and to a dirt track. Kate has had a lot of knee problems and can only run slowly once a week so even though I was tired the 2.5 mile run wasn’t too exhausting. It is incredibly flat here so there are no hills to run up; you just have to deal with the heat and humidity which are a killer for me. The clouds were rolling in fast so it was good that the run was on the shorter side. Just 5 minutes after I got back the skies opened up and it poured! Just as I was about to meet Kate to go out to dinner, the power went out. We were planning on going to the Protea hotel for dinner since it’s the only other restaurant in town but when we drove by they also didn’t have power. Luckily there are two power grids in Katima so we drove to the other side of town and discovered that they had electricity. By the time we finished dinner the power was back on but it was still raining like crazy. I need to buy an umbrella.

We decided that both teams should stay in the office on Friday to have time to prepare for next week so we had a relatively easy day. Kate is super organized and had come up with a long to-do list and we divided up the tasks and set to work. We ran some errands in town and bought some supplies then did some office work. Before long it was quitting time and we left promptly at 5 and headed to the Protea for a sundowner (what they call happy hour here).

The Protea is right on the Zambezi river so I got a good view of it for the first time.

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With all of the rain here and in Angola it is very high. Usually there are hippos that live nearby but their sandbar has become flooded so they have moved to other areas. I didn’t see any crocs either but I’m sure they are there. It was very pleasant to sit out and watch the sun set over the river. In one directions we could see another storm moving in and it was very dramatic. As tough as it is to live and work here, it is very pretty and I’m glad to have these experiences.

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We found two index cases of malaria in the same village so decided to investigate there on Wednesday. It was easy to find the first case but there was no GR-ID on the household so we had to identify the six closest houses on the fly. While the nurses set up, Vincent (one of the drivers) and I headed one way to count occupied houses while Kate and Braster went the other way. Vincent is very familiar with this area and knows some of the people so he knew when several buildings were owned by the same family and when a house was empty. We found the other index case, who actually lived in a different location than what they reported at the clinic, then headed back to the trucks to reconvene. When we got there, we learned from Kate and Braster that a primary boarding school was just next door to the other index case and that one of their staff members was diagnosed with malaria the week before. We had to test everyone at the school since it’s the right and ethical thing to do (and it’s in our protocol), but we knew it was not going to be easy.

The school, God Cares Primary School, was set up and run by missionaries from Romania. All of the staff are European but all of the kids are from the area. The principal was nice but had a lot of questions for us about the study and malaria in general and I wasn’t quite sure what to make of her. But she let us use one of the preschool rooms and provided consent for all of the students on behalf of their parents. Some of the kids just come to the school during the day, but 55 of them board there full time or at least during the week and it was those students and the staff that we really wanted to test.

It was pure chaos for a while. Large groups of kids were hanging around outside, more of them were peeking in the windows trying to see what was going on. All of them were yelling. The teacher whose room we took over wasn’t very helpful in organizing anything. We were told that all of the students speak English (the European staff certainly don’t speak Silozi) but the youngest ones were very shy and difficult to understand so I left most of the interviews for the staff who could speak the kid’s first language. At times it was so loud that I could hardly think clearly and it seemed like there were kids everywhere. It was hard to keep track of who had been interviewed, who still needed testing, who was waiting for results and who was just hanging around because it was the most interesting thing they had seen in a while.

Eventually we worked out a system where Simataa wrote down the kids’ names, ages and genders then got them to sit in a few chairs while waiting for a nurse. As soon as one of the two nurses was free, they would get a kid from the line and test them and collect a DBS sample. Then the child would be sent to Vincent or Braster who would interview them. We had them wait in an outer room for their test result which was probably not the best idea since it made that room very loud.

We all worked non-stop for 5 hours at the school, plus another hour or so beforehand. I didn’t eat or drink anything for over 7 hours and sweated buckets in that hot, stuffy room. I ate “lunch” at 5:30 pm on the drive back to the office.

After the teams left, Kate and I finished up a few things at the office then went back to her place to make dinner. It was nice to take the time to make a good meal. I made pesto pasta with veggies and a salad on the side and felt like we ate like queens. Even after dinner we continued to work for a while, but the 12+ hour days were taking it’s toll and at 9 pm I called it since I was not being productive at all.


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On Tuesday morning I got introduced to the “situation room”. This is a container office that UCSF paid for and had installed at the Katima Mulilo Hospital, which is where the Ministry of Health has their regional offices. It is still getting set up and right now there’s just a table and three chairs inside, but once the burglar bars get installed on the windows, a projector, computer, and printer will live there permanently. Two white boards have been installed and four more are on their way.

Each team stays in the office one day and week and on that day, the team leader (Flavian or Simataa) go to the Situation Room to use the online database to pick out which cases to follow up on that week. The container got that name because Kate jokingly called it that one day and all of the staff picked up on it. I think it’s quite fitting. The container is placed there, instead of at the UNAM office, so that we can easily meet with Ministry of Health malaria team. Our study is taking place in their area and it was agreed that we would follow up on all cases in our study area and the MoH would work on all others. But since the rains started a few weeks ago, there is a huge outbreak of malaria going on and this has lead to some tough conversations with the Ministry about who has jurisdiction. The MoH wants to test and treat everyone, which is great, but would completely invalidate our study. But they don’t have the staff or resources to actually do that, so we have tried to convince them to follow up on cases outside of our area and then if they finish with those (which is highly unlikely), they can work in our areas as well. I’m not sure how that is going to work out.

Anyway, I got introduced to the online reporting system and how the team leaders go about deciding what cases to investigate that week. Then I went back to the office, joined the one team going out to the field and we packed up and headed out.

The rainy season typically starts in October to December but this year it didn’t start until the of January. Last year it was even worse: there was no long rainy season. The result has been severe drought and that has meant failed crops for most people in the area who rely on subsistence farming to live. The government has started giving out food aid, mostly in the form of rice and corn meal (maize meal or pap as it is called here) but it is not enough and people are dying of starvation. And since the rains started so late, it is hard to say if the crops will grow well enough before winter sets in. The situation is getting pretty dire and I feel so bad for everyone here.

This has also added another challenge to our study. When we approached a new village to start a case investigation, many people were not home and their neighbors reported that they were out waiting for their food aid. They often have to walk several kilometers (very few people have cars here) then wait in line before walking home (carrying a 30 pound bag of corn meal) so it is difficult to predict how long that process takes or when someone will be back.

As the teams interviewed and tested the people who were home, Kate and I watched the clouds roll in on a stiff wind.

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It is very flat here, and you could definitely call it Big Sky Country, so the clouds always look very dramatic.

Sometimes there is an awning or shelter (i.e. tin roof supported by sticks but no walls) built by the community where we can do the interviews and testing/treatment, but most of the time we just set up underneath the largest tree in the area which provides the most shade and get to work there. When it is windy, papers and study supplies get blown around and when it’s raining, well, there are issues.

The wind really picked up in the afternoon and you could see the storm coming, so Kate and I started setting up the gazebo that we brought along, but it was too big and awkward for just the two of us to set up. We got Simataa and Braster (one of the drivers) to help, and the four of us working together managed to raise the roof and put on one wall. But now we had created a sail and the stakes we put into the sand did very little to hold the gazebo in place. By the time we got it set up and moved our supplies underneath, a few more of the villagers returned with their food aid. We thought we could enroll and test them then, but they and everyone else who had gathered started running for their houses to get out of the rain and to start preparing food. There was no point in hanging around so we started packing up while the wind speed continued to increase. We got the gazebo down (it was only set up for about 10 minutes) and got most of the supplies in the back of the bakkie when it started to rain.

We quickly jumped in the truck and headed back. At first the rain was just a steady stream, but pretty soon the clouds really opened up and let loose. It rained so hard you could hardly see anything out of the front windshield. Even Simataa started taking video of the storm and he’s from here!

It was such a long distance from where we were to the office that we actually drove through the storm and by the time we got back, it was only sprinkling in Katima. But there were a lot of puddles (i.e. mosquito breeding grounds) and new potholes in the road. On the drive back Kate and I discussed options for the teams when it is raining so hard. This could go on for months so it’s not like we can just not go out and wait for the weather to improve, but we don’t have a great plan yet and it’s definitely something that we have to work out.

The up side to a big storm is an amazing sunset. I always think that the sunsets in Africa are some of the best I’ve seen and I wasn’t disappointed that night as we left the office and saw this:

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Into the field

On Monday morning I went to the office in Katima for the first time. The project’s office is located at the University of Namibia (UNAM) and the Katima campus is new and very modern. The buildings are either brick or concrete and the campus is laid out nicely. It’s so dry out here that grass can’t grow, so the common grounds are bare or just have a few bushes. Some might think that it makes the campus look dingy but I disagree; you just have to look beyond the dry, cracked ground. Our office is in a wing next to the largest lecture hall on campus. Although the office is not very big, they have made the most of it with shelves, a computer and printer, and a table that takes up most of the space. There’s also a storage cabinet in the hallway as well as a freezer to store the dried blood spot samples, and a large storage room around the back. The room is a bit crowded, so Kate and I took our conference Skype call from a small room near the bathroom. You make do with what you have. I’ll upload some more pictures when I have the chance.

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After getting a brief overview of the office and trying to connect with San Francisco on Skype, Kate and I went to the boardroom where we have our weekly staff meeting. Everyone starts work at 8 am in Namibia and knocks off at 5 pm (with one hour for lunch). Ideally, what should happen on Mondays is that everyone comes in at 8 am, packs the trucks (they are called bakkies here, like in South Africa) and gets to the staff meeting at 8:30. Note the word “ideally”; I think this is a rare occurrence. We went through introductions and the normal business. There are multiple projects going on in our office and the staff meeting is the only time that everyone is together to hear what the other projects are doing. The meeting was done in an hour and then we broke to get to the day’s work. Our teams weren’t quite packed and as it became 10 then 10:30 am, I wondered if we would ever leave the office. But then Kate said that they actually were faster today than other days and she thought that things were getting faster. I guess I have to remember the second rule of field work: low expectations.

Eventually we got on the road and headed out. Namibia is big! Even though we are only working in a part of the Zambezi region, there is a lot of driving involved. The closest study area to our office is about 50 km away and the farthest reaches are more than 120 km. The main roads are paved, but some of the smaller ones are dirt so the driving is slower. It can easily take an hour or more to get to a village, in each direction. With an 8 hour work day, that means about 6 hours in the field to investigate a case, which is not much time. The travel distance is definitely an obstacle.

During these first few weeks, the two teams have been going to the same site and working together to investigate a case, but soon enough they will be going on their own so we can investigate more cases each day. Each team consists of a team leader or who organizes the work and decides which cases to investigate when, a nurse who conducts the rapid malaria tests and collects the dried blood spots, and a driver who also conducts some of the investigation. Today we were doing a second visit for a case that the team started the previous week. Some of the people who lived nearby were not home when the team first came and so we try to visit 2 or 3 times to capture everyone who lives in the area. We got to the area and the teams got to work, going to households and asking if the residents were there today. My and Kate’s job in the field is more supervision than anything else. Although English is the official language of Namibia, most people speak several languages and especially in the north and more rural areas, some people don’t speak English fluently enough for me or Kate to interview them. That means we are kind of useless when it comes to some of the study activities. But we help in setting up the tables and chairs, the nurse’s testing station, and making sure that all forms get filled out correctly.

Before the study started, several teams spent months traveling around the study area, recording the GPS coordinates of all of the houses in each enumeration area and assigning an ID number to them (we call it a GR-ID for geographic reconnaissance). Everyone who lives in those households also go the same GR-ID sticker put in their health passport. Theoretically, when a person comes into a clinic in our study area and gets diagnosed with malaria, the nurse completes a case investigation form, which includes a space for the GR-ID, then enters the data into a tablet that gets uploaded to a rapid reporting system that UCSF designed for the Ministry of Health. Every day our team leaders download the newly reported cases and pick one to investigate. Because the nurse entered the GR-ID into the rapid reporting system, we automatically have the GPS coordinates of the case and can locate their house easily. Of course, this rarely happens. About one third of the cases do not have a GR-ID associated with them.

Here’s a picture of a pretty typical village in our study area:

2016-03-07 12.50.00

Most people build their own houses out of sand, dirt, trees and water. It must be a lot of work.

2016-03-07 15.23.21

When we do not have a GR-ID associated with a case then we have to drive to the village and ask around until we find the person or find someone who knows the person and can direct us to their house. This can take some doing, but for the most part the villages are small and most people know their neighbors. It is a time consuming process though. For every index case from the health facility, we hope to interview and test (or treat) everyone who lives in that house plus the 6 houses which are closest to it as the crow flies. If the houses do not have a GR-ID, then the driver from our team will go around and make a map by hand then assign a GR-ID to the house. We have a portable QR printer with us so we can print the GR-ID barcodes in the field and post them in the houses and health passports.

When the GR-ID has been assigned (or is already there) and someone is home, then the driver will talk to the head of the household and get the names, ages, and genders of everyone who lives there (and by lives there, we mean the people who eat their meals there and spent the majority of the nights per week sleeping there). Many times an entire village will be composed of a single large, extended family so a family member might sleep in one building but eat their meals in another one. Or they eat at one building a few times a week and at a different place the other days. Sometimes it is very difficult to determine where someone lives.

Another challenge is that everyone has multiple names: there is their Christian name, their tribal name, and sometimes multiple surnames. So if you go and ask someone “do you know so-and-so”, they might know the person but not recognize the name. And it goes without saying that there are no addresses here; there aren’t even street names for the most part, except for the major paved roads. The villages aren’t even labeled in any way; the local people just know what places are named.

Many people out here herd cattle and goats. We see them every day, often times hanging out on the road so that you have to slow down and honk the horn to get them to move.

2016-03-09 11.35.09

There are also dogs everywhere (and a few cats). I see puppies all the time. I want to pet them, but I refrain because I am afraid of getting fleas or mange. But they are so cute!

2016-03-07 14.17.27 2016-03-10 15.43.31

Needless to say, and the moral of any public health project, it is easy to write a protocol in San Francisco or somewhere else in America, and it is quite another thing to implement it in the field. There are always many obstacles that you don’t expect or couldn’t have predicted. All you can do is make the most of it and do the best you can.

Anyway, things never go as smoothly as one would hope, but you just have to roll with the punches and celebrate the small victories.

According to Kate, the teams have been getting a lot better at their daily tasks and the work is starting to flow better. I shadowed all of the team members and had them show me what they were doing. I know I slowed them down a bit, but they were all very nice and translated things back into English for me. When we had some free time, Kate and I would chat about how things were going and all of the additional things needed to be done to get things running more smoothly. Our to-do list seems never ending and every time we cross one thing off the list, we add at least three more.

Despite how much more there is to do, the teams are getting good work done. They are following the study procedures, asking questions when they don’t know what to do, and filling out most of the forms correctly. There’s probably not as much attention to detail as Kate or I would give, but considering that some of our staff had never used a tablet and didn’t know how to search the internet before they started working on this project, they have come a long way.

We reached a good stopping point around 4:30 so we packed up everything and headed back to the office. Everyone was tired by the time we got back and quickly unpacked then left. Kate and I went back to her place and took a few Skype calls with people in San Francisco then caught up on email and did a few other work related things. We made dinner while on Skype and finally at 10 pm we called it a night.

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On Sunday morning Kate picked me up and we drove to the domestic airport for our flight to Katima, where our field site is located. Windhoek actually has two airports: the international airport, which is located outside of town, and the domestic airport, which is right next to downtown. Only Air Namibia operates flights from the domestic airport and there is only one ticket counter. The same two people sell tickets in person, check people in, and load the luggage into the planes so if you want to buy a ticket in person, you should know the flight schedule because sometimes the ticket counter will be closed while the staff load the luggage. Needless to say, there is only one landing strip. There are flights two and from Katima Mulilo four days a week and the flight makes a loop with one other city but the order of cities switches every other day so sometimes it’s a direct flight to Katima and other times you have a short stop. Like I said: it is a sparsely populated country and there’s not enough demand to justify more flights.

It is just over an hour flight from Windhoek to Katima, which gives you a sense of scale in the country. Katima is in the northeastern part of Namibia, on the pan handle that extends out along the Zambezi river. Here’s a map of the Zambezi region; the dark green is the area in which I will be working. Katima is not actually shown on the map because it’s health facility is not in our catchment area, but it is located on the northern border where the red lines (roads) meet.

Zambezi map

From the plane you can get a sense of how flat Namibia is in the north. I couldn’t even see anything I would consider a hill, let alone mountains. And it is incredibly dry. There are a lot of acacia trees and shrubs, but not a lot of green. And with the drought, even the rivers are low for this time of year.

When we got picked up from the airport, we drove into town and I saw a road sign that said “Zambia 3 km”. I am just a short drive from the Zambezi river which marks the border between Namibia and Zambia and Angola.

Katima is a small city/large town with a population of about 30,000 people (read the wikipedia page here) and it’s elevation is 3,100 feet above sea level. There’s not much going on in town: there are two restaurants, two grocery stores, a few other shops, one university campus (where our office is located), and two or three main roads. The main roads are tarred (paved), but the smaller roads even in town are dirt. It has rained here recently which has created a lot of bumps and divots in the dirt roads so driving is slow going. But no one’s in a rush here so that’s alright.

We stopped at my guesthouse to drop off my stuff before getting lunch and grocery shopping. Right now I’m staying at a place called Geoline Guesthouse. It is pronounced “Joleen” because the owners are named George and Pauline. The owners live in the front building which has the office and in the back there are 3 guest rooms, a tiny pool, and a building where breakfast is served which has a small kitchen area. My room has two twin beds abutting each other, but it is not a king bed. There’s a mini fridge, wardrobe, TV, A/C and small desk. The bathroom is large and has a huge shower. The tile floor has a nice pattern. Overall it’s a good place to stay for the area but it’s not the Ritz. It’s better than some places that I’ve stayed in Africa though; the WiFi is great and it’s just a few blocks to the flat where Kate stays. It could definitely be worse.

UCSF rents a flat for Kate (or whoever else is up here), but it’s a one bedroom with bunk beds in the living room. Her shower is in the corner of the bedroom and is in clear view of the living room when the door is open, so staying with Kate is not a great option. However, if she’s ever in Windhoek I can easily stay there if I want.

We went to one of the two restaurants for lunch, called Passione. They advertise themselves as Portuguese but although I have never been to Portugal, I’m guessing that the food there is quite different. Passione has a lot of meat and chips (i.e. french fries) on their menu, along with some fish and pizza. And this is the restaurant with better vegetarian options!

Luckily we went grocery shopping right afterward and I was really impressed with the assortment of food at Pick and Pay. I found some frozen salmon and hake fillets and even some veggie burgers and fake-meat crumble. The veg selection was not good, but Kate says they get all of their produce on Mondays so we’ll go back tomorrow to see if the selection is better. I found one yogurt that doesn’t have sugar added, a few kinds of canned beans and even chia seeds! Overall I’m sure I’ll eat a lot better than when I was in South Africa or Zimbabwe so I’m very happy about that.

It was really nice to actually unpack my luggage this afternoon so now it doesn’t totally feel like I’m living out of my suitcase.

I thought I would be the only person at Geoline, but when we were at the airport, Kate and I met Andrew, another UCSF employee who is based in Namibia working on HIV research and his colleague, Abigail. They were supposed to stay at a guesthouse down the street but there was an issue with Abigail’s reservation and they both decided to stay at Geoline instead. They are only here for a few days, but it will be nice to have some company.

After settling in, I met Kate at her place for dinner and we enjoyed curried salmon with rice, butternut and sweet potatoes (the veggies were frozen and not the best, but what can you do). While eating we made our plans for Monday when I’ll go into the field for the first time. I know it will be tiring, sweaty work but I’m looking forward to seeing more of the country and observing how people live. I’ll try to take some pictures to give you an idea of what it’s like out here.

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Now that I’ve found some good maps, I can give you some context about Namibia and where I’ll be working.

This is Africa and Namibia is highlighted:

namibia map

Here’s an up-close map of Namibia:

namibia map 2

Namibia has a beautiful flag which is prominently displayed on many streets:

Namibia flag

Windhoek is the capitol and the largest city; it has a population just over 325,000 people. There are only 2.1 million people in all of Namibia. Think about that: many cities have more people than that. Namibia is one of the least densely populated countries in the world. According to Wikipedia, there are 6.6 people/ square mile, which ranks it at 235th in terms of population density (To read more about Namibia, click here). That means there’s a lot of empty space and things are far apart.

After spending one night in Johannesburg, I flew to Windhoek (the only city with an international airport) on Friday morning. It’s just a two hour flight, so compared to the flight I had just taken, it was a puddle jump.

I was met at the airport and taken to my hotel, which was right next to one of two malls in Windhoek. After getting settled in and catching up on some email, I met up with Kate, who is an American employed by UCSF (and in my department) but who is permanently stationed in Windhoek. Kate has been living here for two years and is the program manager for the various studies going on in the country that our department has going on. I had spoken to her on Skype a few times before I left and she gave me a lot of good advise about what to bring and what to expect. She’s been a great resource and I’m sure we will work well together. We chatted for an hour or so and made a plan for the next few days.

Afterward, I went across the street to the mall to check it out. Walking in there, I felt like I had been transported back to South Africa: I recognized all of the stores, restaurants, and banks. This is because most chain stores in Namibia are South African owned and based. There is only one Namibian clothing store (and the clothes are made in China). The mall is just like any American indoor mall except the names of the stores are different. I picked up a few snacks at one of the grocery stores, but mostly wandered around to stretch my legs and kill some time.

Kate recommended the sushi restaurant attached to my hotel so I went there for dinner. There were a few other people in the restaurant, but it wasn’t packed or overflowing. After I ordered the waitress said it might be awhile for my food. That was fine. It was a pleasant evening, I was sitting outside, enjoying the sunset and I had my book. Two hours later I was still waiting for my food! It was the longest I had ever waited for service. I would have just left, but I didn’t know if the mall was still open. Eventually I got my food, which was good but not comparable to sushi in the Bay Area, and was comped for the appetizer. You have to be ready for anything in Africa and have a lot of patience!

I knew I was still behind on sleep since I didn’t get much on the way over but I had a hard time getting to sleep so ended up reading until 12:30 am. Which would have been fine, except that I woke up at 4 am and couldn’t get back to sleep. After laying in bed for half an hour, I started reading again. I brought two 800 page novels thinking that would be more than enough for two months, but I’m already half way through the first one and I’ve only been gone for 4 days! Good thing I have my kindle.

Saturday was an easy and relaxing day. I met up with Kate at the mall and we ran some errands for work. I tried to get a SIM card for my phone, but the cell phone store said their system was down and they couldn’t complete the transaction. I checked back with them twice more that day but had no more success.

Windhoek is not a very large city and I saw most of the downtown area while running errands. There’s not much to report and I didn’t take any pictures. There are two malls, other small shops, a few city parks, and some office buildings. No skyscrapers, not a lot of traffic (although it was Saturday), and not much going on. Most shops close early on Saturday but I didn’t really get the impression that it would be very crowded otherwise. There is a lot of construction going on though. There is a lot of urbanization across Africa and Namibia is no exception. Many people are flocking to Windhoek and it is expanding at a fast rate.

Windhoek is situated on a large plateau and is over 5,000 feet above sea level. It’s about the altitude of Denver, but you don’t realize it because there are no mountains in the area to give things perspective.

March is still summer here and it is hot. The highs are in the upper 80s and lows in the 60s. It’s also the rainy season although there has been a severe drought for the past two years. Most of Namibia is a desert or very arid ecosystem and most of the country’s water comes from desalination, which makes it very expensive. Windhoek was founded because there used to be a natural spring in the area but I don’t know if it is still running.

Namibia is 10 hours ahead of PST (and 7 hours ahead of EST). There is also daylight savings time but that does not go into affect until some time in April. Sunrise is around 6:50 am right now and sunset is around 7:15 pm.

I was really tired that afternoon from both jet lag and lack of sleep so I declined an offer from Kate to join her at a friend’s party and instead did a bit of work then read some more, hoping that sleep would come more swiftly than the previous night.

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2016 Adventure

It’s been 11 months since I embarked on my last adventure (hiking the entire Pacific Crest Trail) and now I’m in transit to the next one, this one for work. Two weeks ago I started a new job working at the University of California, San Francisco in the Malaria Elimination Initiative (MEI). The name of the department is pretty self-explanatory: MEI works with and in countries with a low burden (few cases) of malaria, with the goal of halting local transmission and ultimately eliminating the parasite. There are 34 countries in the world who are working toward malaria elimination, according to MEI (although any country can say they are working on it, without actually *doing* anything). Most of the countries are in southern Africa and Southeast Asia.


In particular, Namibia, in south western Africa, is aiming to eliminate local transmission of malaria by 2020. They have made great strides toward this goal, but now that malaria is under control and not present in most of the country, the government needs to change tactics in order to go from a few cases of malaria to zero cases. That’s where UCSF and MEI come in. Namibia’s Ministry of Health and Social Services (MoHSS), the University of Namibia (UNAM), and MEI have been working together since 2012 to improve the country’s malaria surveillance system and capacity for operational research. Namibia has now implemented reactive case detection (RACD) in much of the country, but these efforts will probably not be enough to eliminate malaria. In reactive case detection, when someone comes to a clinic or hospital and is diagnosed with malaria (via a rapid diagnostic test, RDT, or microscopy) and treated, then theoretically, an official from the MoHSS will travel to that person’s home and test everyone who lives in the same house and any house within 200 meters of it. Since the mosquitos that spread the malaria parasite don’t typically fly very far, the people spend a lot of time close to a malaria case are at the highest risk of contracting the disease. Any close contact to a case who tests positive for malaria would be treated with a standard 3 day course of Artinimisinin combination therapy (ACT). This works great when there is a lot of malaria parasite in someone’s blood because then the RDT is very sensitive and specific. However, in areas of low transmission, such as Namibia, it has been shown that some people will harbor the parasite in their blood but not show any symptoms; they don’t feel sick (or sick enough to seek treatment) and they can also test negative by the RDT, but they can still transmit the parasite to a mosquito and hence to another person. While RACD is great in some situations, it is probably not enough to eliminate malaria.


To try to interrupt transmission, UNAM, MEI, the Gates Foundation and the Novartis Foundation are now working together on a clinical trial comparing RACD to targeted parasite elimination (TPE). TPE, is a system in which the people who are at highest risk of contracting malaria, the people who live in the same house or a house within 200 meters of someone diagnosed with malaria, are presumptively treated, or given malaria drugs to take even though they have not been diagnosed as having malaria. TPE is a type of mass drug administration (MDA) which is very common in some parts of the world for several diseases and TPE has been shown to be effective in stopping malaria transmission in China. However, it has never been attempted in Africa and no one knows if it is feasible, cost effective, accepted by the local people, or is better than RACD. In the study that I will be taking part in, we will test the hypothesis that TPE is more effective than RACD at decreasing malaria incidence.


In addition to testing TPE vs. RACD, the study will also test whether indoor residual spraying (IRS) or reactive vector control (RAVC), or spraying the inside of index cases’ houses, provides an additional benefit. The MoHSS does annual spraying of houses in high risk areas but some houses are missed or not sprayed well, so we are testing whether an additional level of spraying, with a different insecticide, will make a difference.


The difficulty in doing this type of research is that there are not that many cases of malaria in Namibia. In 2001 there were over 500,000 reported cases but in 2013 there were only 4,700 in the country. That is amazing progress, but there is the risk that there won’t be enough cases in each arm of this study to statistically detect a difference in incidence over the two years that the study is going on. While we want fewer cases of malaria, we want enough cases to know that TPE with or without IRS made a difference.


And now, I’m on my way to Namibia to help collect the data for this study. For those who don’t know, Namibia is in south west Africa. It borders South Africa, Bostwana, Angola, and Zambia. Most of Namibia is desert and doesn’t have malaria, however, there is a small strip of land in the northeastern part of the country which extends out like a pot handle and is right on the Zambezi River and hence part of the Okavango delta. With the rain and river, this area is at higher risk of malaria transmission and is where I will be working (I’ll add a map later because I’m having difficulties with it now).



The region where I will be working is called the Zambezi region (named after the river) and the town I will be based in (after a weekend in the capitol, Windhoek) is called Katima Mulilo, or Katima for short. It is right on the Zambezi River and is a regional capitol. Since Namibia is a relatively rich country, people from Angola, Zambia, Zimbabwe, and other countries come to Katima to buy goods and food not available elsewhere and also come here for work. With all of the cross-border travel, there is an increased risk of someone importing malaria (and other diseases) to this region.


Because of the proximity to the river, the main economic driver in the area is agriculture. During some seasons of the year, farm workers and laborers are outside in the fields late at night, which is when the mosquitos that transmit malaria are most active. That means farm workers have an increased risk of getting malaria.


Another common activity, other than hanging out at outdoor bars (because it is so warm at night) is attending night churches. These church gatherings are also outside, so there are several different demographics of people at increased risk of malaria in this region.


I’m not sure why this sliver of land belongs to Namibia versus another country (but that is a question I will definitely figure out once I’m there), but the people who are native to the area speak a different language (SiLozi) than most other people in Namibia. Because of this and the distance to Windhoek, the Zambezi region has often been neglected by the central government and doesn’t get the resources that it really needs. There is a UNAM campus in Katima and I’m told that the town has two restaurants and a decent grocery store. Based on this alone, it already sounds better than the Northwest Province of South Africa where I was working two years ago.


Right now I’m in Johannesburg where I will spend the night before flying to Windhoek in the morning. I’ll be in Windhoek until Monday morning when my colleague, Kate, and I will fly to Katima and I’ll start going into the field to supervise data collection. It’s hard to believe that just over two weeks ago I didn’t have a job and now I am half way around the world, embarking on a new adventure. I hope you will join me and will enjoy reading about it.

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