O Belo Horrivel

O belo horrivel

I began to hear this term, O belo horrivel, during my time with my family in the Açores. A direct translation is “the beautiful-horrible”. They used it to describe something that is quite striking but devastating. For example, powerful waves that crash against a shore, an erupting volcano, or the favelas (slums) surrounding the city of Rio de Janeiro. There can be a beautiful aesthetic to things that, in reality, can be quite horrific. O belo horrivel is the term I use now to describe the flooding I witnessed in the north of Namibia.

Many of you have already heard me mention the flooding that has been taking place here. It reached emergency levels by April. Namibia received double its normal seasonal rainfall - in just 4 weeks. Over 260 schools closed, 40 health clinics were under water, and more than 100 health mobile outreach points have been made inaccessible as a result of damage to roads and bridges. Many of our malaria interventions were completely brought to a standstill. For instance, the access roads, used by trucks to transport vital bed nets to some of the remote villages, were completely submerged. About 40,000 people have been displaced, some 10,000 of whom have been accommodated in 68 camps set up by the government. This was especially complex for Namibia since this flooding fell at the same time as malaria season. The Red Cross estimated that 500,000 people have been affected, with the densely populated central-northern regions (Omusati, Oshana and Ohangwena) hit worst. These areas are malaria endemic zones, and are exactly where most of our work takes place.

Cemetery, also threatened by the floods:

Currently, one of our major projects is a bed net distribution pilot that we are conducting in Ohangwena. I was asked to fly north to our target region at the border of Angola to assess the flood damages and to see if the project could continue as planned, and if so, what adjustments would need to be done so we could manage this operation during the flooding. I would also meet with our partner NGO in the project, Nets for Life, and would assemble the community leaders to discuss the plans and to gain their support in the net distribution project. Time to get busy.  

I left on a tiny plane filled with some concerned relatives, two folks from the Red Cross, and two from the UNHCR (for my non public-healthers, the UN refugee agency). I talked with one of the UN guys for the whole trip. During the last ten years, most of his refugee work has been done in Thailand and Kenya. I enjoyed our conversations, and he was very nice. However, he also seemed programmed and robotic with his talk about emergency situations. I guess you need to be stoic in order to cope with the constant exposure to traumatic events, but I never want to end up that way…

When we were getting close to the flood zone, I could already see the damage from the air. So much water…. in an area that is completely barren 90% of the year.

It was strange when I arrived in Ondangwa (our closest town with an airport), because my feelings were completely mixed. Part of me was so excited to visit some of the remote areas of the country. The other half of me was saddened by seeing the floods in real-time. I was in awe the whole trip, and I had to keep reminding myself that all the water I saw does not belong there, and that the levels were even higher the weeks before I arrived. The main road, at this point in time, was in working condition, but everything to the left and right was in a water world. 

The first day consisted of meeting up with my colleagues from Nets for Life. The coordinator, Jackie, I have met a number of times already in Windhoek and is my main contact for the work in the North. She is a wonderful older woman from the UK who is a pleasure to work with. She definitely gives off the caring mom/grandmother vibe, and her disposition helps us receive a very warm response from the community. I really enjoy the whole group though, and besides Jackie, are all Namibian. Lorna and Helvi are my main local contacts on the ground. You can tell they all really respect and value their jobs, and feel very proud to help their country and community. I couldn’t help but feel energized by their outlook.  

Here is Jackie, Helvi, and our ‘netman’ Shikomba: 

Shikomba proudly showing us our nets:

We had lots of prep work for our presentation the next day to the community leaders. We needed to go through all the translations with the local staff to be sure to pick the appropriate words in the local language, oshivambo, that could equate to some of the more abstract scientific terms, like “parasite” and “vector”. I think oshivambo is a very pretty language and I will try to learn a bit while I am here. It is spoken by the Ovambo people, who represent a majority here in Namibia. (That being said, there are many races, tribes, and languages throughout the country). My first oshivambo word was “nawa”, which basically means “all is well”.

After our prep work, we took the time to go meet some of our other partners and contacts in the area, and to see our main target village, Odibo.

Here is a pic as we entered the village area:

We met the head clinic nurse, ‘Meme’ Anna. She was a sweet old lady, and I was honored that she was so eager to show us around the clinic. She just assumed I was a doctor, and took me through all the wards. I had the chance to meet the staff and nurses, who greeted me so warmly, it was one of the best feelings I have had so far in Namibia. It was something amazing to finally see a clinic like this first hand, after all the years of studying about these minimalistic health systems. Eye-opening to say the least. (I did not find it appropriate to take any pictures during my tour, at least on the first time through. I will be back for more visits). Some of the facilities were in definite ruin but there is no available money for reconstruction. Not purposely using a health example, but they just keep putting band-aids on open wounds. I am hoping that we can try to generate some funds to rebuild the clinic, and will be sure to run this by some of the donors.

Seeing trees and houses just sprouting from the water was bizarre and heartbreaking. Witnessing all the damage took its toll on us, but as I mentioned, the water was truly beautiful at times.

Even the horses had to deal with the floods:

what to do:

However, through all those images that were hard to digest, came glimpses of hope and resilience. With the floods, came the fishermen!


Some of the people I met had great attitudes, and were great innovators. One thing observed in the north was that some people were using their malaria bed nets as fishing nets! Ha! Had to give them credit. Priorities change in emergency situations. One of our proposed interventions would be to give out a fishing net with each malaria net, to promote proper use of each. Possibly too late for this rainy season, but something we can prepare for next year.

The next day, I was exciting to finally meet the community leaders. The purpose of the meeting was to inform the leaders on what we planned on doing in their communities and how we needed their support in communicating with the rest of the villagers. We would need their help in picking volunteers to assist in our net distributions and surveys. The first part of the project is just determining the correct number of people per household, so we know how many nets to give out. Along with distributing the nets, the project will have an educational component. At the start, we will conduct a baseline survey in 1 out of every 10 households to gather information on malaria prevention behavior and general knowledge of the disease. Every month, community volunteers will visit the homes to see if the families are still using the nets and to give brief education and reminders on malaria prevention practices. After 12-15 months we will go back to these households with another survey to see if their knowledge, attitudes, and practices (KAPs) have changed with regards to malaria prevention. To find these same homes again (some households are quite remote), we will capture their coordinates using PDA devices at the start of the project. 

We had no idea how many people would actually show up to the meeting. We invited all village leaders (27) as well as the main priest of the community, and head nurses of the health clinics. The meeting was set for 10am, and at 10:15 we had everyone show up! (We were blown away. Any of my friends that have been in Africa are well aware of ‘African Time’). We had 25 out of the 27 leaders attend (2 were sick), with their “secretaries”. Some villages had up to 3 representatives, so we had a small room filled with about 65 people. Not one seat was empty, and we were even scrambling for extra space. It was pleasantly packed. 

Two of the headmen:

After we reviewed the project and expectations of the leaders, we had a review session on malaria prevention and treatment recommendations, as well as a simple background on the disease and how it spreads.

We were very happy with the engagement of the community leaders. They seemed responsive to our comments, seemed to listen and follow along with our handouts and presentations, and asked some really insightful questions. I was quite impressed. They all seemed to recognize the importance of the project, and were very thankful for us being there. It felt great. We had all village leaders pledge their support for our work, and the meeting was a success. It was a tremendous relief. I did not want to feel like we were imposing on the community or have them think what the hell we were doing there. Without their backing, we could not have moved forward. Now that we had the leaders’ support, we needed the them to pick their volunteers. Once this is completed, we will run a training session with all of them in late May/early June. Of course our training center was under water, so we had to find a new location, and ended up making an agreement with the local school.  

The head priest talking with one of the clinic nurses:

Leaders pledging their support:

Here is a shot of the full group of village leaders. They were proud to get a group shot of their historical event, and I will happily hang this picture up in the community center:

The rest of the trip involved surveying some of the flood areas.

This distribution project is time sensitive, because we want the community to have universal coverage with their bednets during the peak of the malaria season. We are only going to start distribution in June. Usually the peak of malaria season is April, but with the flooding, this peak has shifted.

Context on the Namibian malaria season - In Namibia, the rainy season is Feb-April. After all the rain, puddles and bodies of water form. Mosquitoes love stagnant water for their breeding. It is their ideal environment. So every year after this rainfall stops in April, the number of mosquitoes is at its peak, hence a higher number of possible malaria carriers (vectors). This malaria season lasts until the waters finally recede and winter approaches with its’ colder temperatures (which the mosquitoes do not like).  This year, the record rainfall stretched all through April into May. This led us to two hypotheses about the total malaria cases that could result. We could have the worst case scenario: all the rainfall leads to a greater number of stagnate bodies of water which leads to even more mosquitoes than normal, which could trigger an epidemic. Or the best case scenario: the rain keeps falling and the bodies of water are constantly disrupted and moving, limiting the amount of stagnate water, which makes the mosquito breeding more difficult. If this continues through May, the cold temperatures could arrive without mosquitoes having their chance to breed. This could result in lower malaria case numbers than normal. This is the scenario that we are of course hoping for. However, we have to prepare for the worst case. So far so good, and the malaria case numbers have been steady but not increasing.

This led to some brain-wrestling, because we want the rain to stop, so the flooding can recede, but at the same time, without the rainfall, the mosquitoes will start to breed. Never easy.

With this seasonal shift this year, we think our distribution timing could be just right, and ready for when the mosquito population reaches its peak, before the winter arrives.

It was fantastic to start the work on the ground, and I really enjoyed being in the community where we will be working. At the same time, it was a draining week seeing the difficulties and destruction from the flooding. The community outlook kept us in perspective though and I will try to keep their faces and smiles in my mind as we continue with our pilot project.

By the time I am posting this entry, communities back home in the United States are also dealing with devastating floods of their own. My heart goes out to them, as I have a new found respect for anyone that has to deal with this kind of disaster. Back here in Namibia, the waters continue to recede and the cold air has arrived. We might have made it past a scary malaria epidemic. We just hope our project has some impact, and prepares the villages for next year. Now we need nature to cooperate so that these good people will not have to deal with this kind of destruction again. Back to business!

 “No loss by flood and lightening, no destruction of cities and temples by the hostile forces of nature, has deprived man of so many noble lives and impulses as those which his intolerance has destroyed”.

-Helen Keller