Finally capping its own medics, the country must now retain them and coax them into rural areas.
It took Simon Antindi three hours, two taxis and one jolting ride in the back of an old farm bakkie to reach the state hospital where his father had been admitted – and when he saw it, he was overwhelmed.
The hospital, in the far northern Namibian town of Oshakati, was bigger than any the 11-year-old had ever seen before – a huddled mass of low-slung green and blue buildings that trailed off into the horizon in every direction. Every turn led him deeper into a maze of crowded wards and worried visitors. Doctors whispered to each other in languages he didn’t recognise and the whole place smelled vaguely sour, like sickness and cleaning fluid.
And then there was his father. The local primary school principal, this was a man who easily filled a room with his authority and his warmth, a man whose generosity was a long-standing source of local pride.
A few years earlier, when the struggle for independence against South African rule blurred into villages and towns all across this part of what was then South West Africa, his father used to slaughter a goat for each passing band of Swapo guerrillas who trekked through – and often got himself arrested for his trouble.
But at the hospital now, he didn’t look like that man at all. Instead, he was small and shrunken against the blank white bed. For the first time in Simon Antindi’s memory, his father looked utterly helpless.
“At that time, I knew I wanted to be a doctor,” says Antindi, now 31.
But no sooner did the thought enter his mind than he shoved it away. “In my village, in my whole constituency probably, there was no one who became a doctor,” he says.
And as he looked around at the Cubans, Russians and South Africans attending to patients all around his dad, he had a sinking thought.
Maybe Namibians don’t do this work.
Maybe we can’t.
And that was it. As quickly as it had come, the dream fluttered away.
But 700km south, in the capital of Windhoek, many of the country’s top medical minds had nearly the same question. It was the late 1990s, nearly a decade since Namibia’s independence from South Africa, and still the country had no medical school of its own. For generations, all of Namibia’s doctors had been trained abroad – shipped off to places like South Africa, Finland and Russia for a medical education that often translated poorly to local conditions, or else they were foreigners, recruited at great expense from overseas.
“We needed to start training doctors sensitive to local roots, who were prepared to go where the needs were,” says Filemon Amaambo, now the associate dean of the University of Namibia’s (Unam’s) school of medicine – the first in the country – who was then working in government.
Namibia’s problem was not unique. Sub-Saharan Africa carries more than a quarter of the world’s disease burden but is home to only 3.5% of its healthcare workers and just 1.7% of its physicians, according to a 2012 article in the open-access journal Human Resources for Health.
The region’s universities have long struggled to fill that gap. There are 175 medical schools serving a population of about a billion people in sub-Saharan Africa, compared to 488 medical schools for a population of 743?million people in Europe.
And six African countries – Cape Verde, Djibouti, Equatorial Guinea, Lesotho, São Tomé and Principe, and Swaziland – have no medical school at all, according to the World Directory of Medical Schools.
That’s a dangerous gap because there is a “strong relationship … between medical school density and physician density”, according to research published in the Medical Teacher journal.
In other words, countries with fewer medical schools tend to have fewer doctors too.
For many in Namibia’s public health sector, the absence of a single medical school stung in a way that was deeply personal.
“We knew it was more than imbibing medical knowledge,” says Amaambo, who arrived at the Durban Medical School – then South Africa’s only institution for training “nonwhite” doctors – in 1971.
“For us, medical school was also always about the need to transform society. We saw ourselves as part of the liberation of our country.”
When he finished medical school in Durban, Amaambo returned to South West Africa and moved immediately to the country’s northern border, where he spent the next decade treating gunshot wounds and landmine injuries at hospitals in the heart of the country’s liberation war against Pretoria.
It was an education, he says, at the brutal intersection of medicine and political repression.
“We saw the inequality of care every day,” he explains.
He and other hospital workers listened to the chop-chop-chop of helicopters taking off from the local airport, airlifting injured white soldiers to hospitals in Pretoria and Johannesburg while black civilians were often left to die in understaffed clinics on the frontlines.
One night, he remembers, a young child was rushed into his emergency room, unable to breathe. It was clear to the young doctor that they needed to get him to a bigger hospital or the boy would die. But a strict military curfew meant that if he sent the ambulance out, everyone inside risked being shot to death by soldiers.
“There was always not just knowledge of anatomy and medicine that we were putting to use,” he says, “but also a broader understanding of why we were doing it.”
So it was no surprise, he says, that in the years immediately after Namibia’s 1990 independence, academics and government officials there began pushing for an investigation into the feasibility of a medical school. But when the study was finally carried out, it found the project too costly for the young country. It was put on ice.
Even as the debate brewed, a growing health crisis was shaking the country’s health system to its core. By the time Simon Antindi visited his father at the hospital in Oshakati as an 11-year-old, a terrifying new illness was creeping across their village, Ondjamba, and countless others in the region.
“People looked like skeletons,” he says, recalling how friends and neighbours wasted away, swerving sharply from health to death before anyone knew what was wrong.
“As kids, we were really afraid.”
Worse still, in a story mirrored across the country and the region, the local hospitals seemed powerless to stop it. People would leave for treatment, Antindi remembers, and then simply come home to die. By the time antiretroviral treatment was rolled out in the early 2000s, HIV was the leading cause of death in Namibia.
For Amaambo, the Aids epidemic underscored the need for the country to train doctors with deep roots in its communities – and particularly in its most remote corners.
“For a long time, we have believed excellence is a privilege – that you deserve the best [care] only if you can afford it,” he says.
But if doctors could be trained locally, he reasoned, maybe Namibia could begin to flip that script – to bring the best care not to those who had the most, but to those who needed it most.
In the early 2000s, with the assistance of Kenyan public health expert Peter Nyarango, the university and government began setting the course to open the country’s first medical school, beginning with the establishment of a two-year “pre-med” course for aspiring doctors. The best would be offered bursaries at foreign medical schools.
The first year of that programme, 2003, also happened to be Antindi’s last year of high school. And as he filled out his application to Unam, his pen hovered over the field of study. “At that time, I had still never seen a Namibian doctor, so I had no confidence,” he says.
Still, he decided to give the new pre-med programme a go.
He was rejected.
The problem was his English score. It was brilliant by the standards of the country’s rural north, where almost no one spoke English as a first language, but middling in the eyes of a Windhoek admissions committee. They had no way of knowing the long, self-taught hours reading novels in the school library that had gone into it.
So Antindi settled for his second choice: a general science degree. He headed for Windhoek, the dream of medical school once again tucked away and forgotten.
And it stayed buried until 2009, when the recently graduated Antindi saw a poster on Unam’s campus, advertising an intake for the first class of the university’s medical school.
Something inside him sparked, he says, remembering that day all those years ago when he had raged at his own helplessness to assist his sick father.
He applied – and six years later, he found himself walking across the stage at a Windhoek hotel as part of the first class of 35 doctors to ever graduate from a Namibian medical school.
Their success was widely celebrated locally, but the school was not without controversy. A massively expensive project, it had involved the construction of an entirely new campus full of angular modern buildings kitted out with mock hospital rooms and high-tech laboratories.
There were whispers that the medical school’s graduates weren’t being trained to international standards. The course, initially set at five years, had to be extended to six to bring the new doctors up to speed before they began their internships.
And the impact on Namibia’s healthcare system has been, at least initially, quite modest: three dozen new doctors in a country that probably needed 5 000, Amaambo says. “So at this pace, it will take us more than 100 years to catch up.”
Since then, Unam has graduated one more class from its medical school and the incoming class size has tripled. The first class of dental students, meanwhile, will begin studies next year.
But for many of the young doctors graduating from the school, this is the beginning of a life they never thought they would lead.
“I think most of us, almost all of us, are the first doctors in our families,” says Llewellyn Titus, a final-year student at the medical school.
His parents raise sheep and goats on a farm 260km south of the capital.
For Antindi, finishing medical school meant one thing. He tucked his diploma in among the boxes and pointed his loaded old Corolla north, towards Ondjamba.
“The whole time I was studying, I knew I was going to come home to work,” he says. “You go to Windhoek to study, but you owe it to your community to come back.”
Amaambo and Nyangaro hope many of their students will see things the same way. Local training, they believe, will prepare them for local conditions and show them the value of working in the places where they come from. They’re currently setting up a community service requirement for the new graduates. This programme has been shown to boost the presence of doctors in understaffed areas in several African countries, including Ethiopia and South Africa.
That’s something Namibia desperately needs. Although the country has more than three health workers per 1 000 people – higher than most other African countries – the figure in the public sector is about two for every 1 000, according to the World Health Organisation (WHO) and Namibia’s ministry of health and social services.
Like South Africa, Namibia’s health system is one of vast and growing inequality, where gleaming private hospitals for the rich sprout constantly, but creaking, overburdened public institutions struggle to care for the majority.
Brain drain remains a major concern. Five years after graduation, more than a fifth of African-trained doctors have migrated outside the continent and only 8.6% are working in a rural public practice, according to data gathered for a 2010 study of sub-Saharan Africa’s medical schools.
But training doctors who come from the communities most in need of healthcare may be the best way to reverse that inequality. According to a 2009 Cochrane systematic review, the single most important factor in determining whether a doctor will practise in a rural area is whether they grew up in one. In neighbouring South Africa, for instance, students from a rural background are three times as likely to work in a rural location, according to the WHO.
For the past 18 months, Antindi has been completing rounds as an intern at the very hospital where he visited his father all those years ago, roaming its halls with a crisp white jacket and a sense of authority he never could have imagined as an 11-year-old.
And he brings to work each day a basic skill still rare among doctors in Namibia: the ability to speak to his patients in their first language.
Most must use nurses as interpreters, adding another layer of distance and intimidation to medical care.
On a recent morning, working his rotation in the anaesthesiology department, Antindi chatted easily with a nine-year-old boy preparing for minor surgery.
While the surgeons and nurses crisscrossed the room around them prepping for the procedure, doctor and patient swapped names and home towns – discovering that they came from nearby villages.
“Just breathe deeply,” Antindi instructed in Oshiwambo as he lifted a mask to cover the boy’s face. “Breathe, breathe,” he murmured as his patient drifted towards unconsciousness.
“I feel at home every day I go to work,” he says. “It doesn’t matter if I’m talking to a doctor or a patient or a cleaner – these are my people. I’m at home here.”
For now, he hopes to stay in the region when he finishes his internship at the end of this year. He hasn’t decided on a speciality yet, but he’s leaning towards obstetrics and gynaecology.
He knows first hand, he says, how many women and babies in this part of the country die in childbirth, and it disturbs him. But even more than that, he says, there’s a joy to hearing the first cry of a newborn that he hasn’t matched anywhere else in his medical experience so far.
“It gives me so much pleasure to look at that baby and get to be the one to say: ‘Hello baby, welcome to the world.'”