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Leaving Windhoek—The Inequality of Life and Death in Namibia

Just a couple of weeks ago, I was walking the wide roads of downtown Windhoek, Namibia, alongside scores of German tourists, who were milling about and visiting African curio shops before heading off on safari at an exclusive bush-lodge. I thought to myself that if this was all you saw of Namibia you might believe that the country has somehow avoided the development pitfalls that have snared so many of its neighbors.

Indeed, the World Bank recently classified Namibia as an upper-middle income country. In certain sectors of the country there are vast amounts of wealth fed by the discovery of diamonds, uranium, and other precious natural resources, and a system of well-maintained roads that literally drive one of the strongest economies in sub-Saharan Africa. Yet, the majority of the two million Namibians live in poverty. It is a stark disparity that has led to Namibia’s ignominious distinction as the nation with the world’s highest Gini coefficient, a measure of inequality.

The eco-tourists and adrenaline junkies who stalk wildlife over the cracked pans of the Etosha or sand-surf down the towering dunes of the Namib Desert don’t often see the other side of Namibia. They may not realize that:

  • Nearly one in six adult Namibians are living with HIV.
  • 50% of Namibians who are eligible for work cannot find regular employment.
  • Over the last 30 years, Namibia has seen a nearly 50% increase in its national maternal mortality ratio even as the global maternal mortality ratio has dropped by nearly 40% over the same period.

To really understand Namibia, you have to leave Windhoek. Recently, I traveled with Dr. Kudakwashe Chani, IntraHealth’s technical director in Namibia, to the Oshikoto region in the northern part of the country where the majority of Namibians live close to the Angola border. Unlike the desert wastelands of southern Namibia, the land in the North can support farming and livestock, and the German and Afrikaner colonial influence is minimal. The people mainly speak Oshiwambo, and life takes on a distinctly African flair, in part perhaps a reflection of the segregation of the northern regions under apartheid. Today, some 20 years after the last shots were fired in the war for independence from South Africa, the scars of this struggle are still visible in the roadside villages made up of concrete hovels or thatched-roof mud huts. Alcohol abuse is a widespread problem in these areas, and seemingly every other building is a tired-looking shabeen—a local bar—full of paying customers any time of day. 

Dr. Chani and I traveled north to assess the ways in which the local, faith-based health facilities that IntraHealth supports with USAID funding could improve the provision of emergency obstetric and neonatal care for women and their newborns. As I mentioned earlier, more women in Namibia are dying from pregnancy-related complications in the past few decades. The latest estimates suggest that 586 women die for every 100,000 live-births.  Deaths among newborns and children under age five are also increasing, and the Ministry of Health is understandably concerned and actively seeking ways to counter these trends.   

As part of this larger, national effort to stem these deaths, Dr. Chani and I visited health facilities managed by three different faith-based partners—Anglicans, Lutherans, and Catholics—to understand the root causes of these unnecessary deaths and identify potential interventions. Because of cost or familiarity or a lack of understanding of the risks, Namibian women often opt for a home delivery supervised by a local birth attendant, who likely is not trained to perform active management of the third stage of labor or to treat or refer in the case of complications. When women do deliver in the clinic, they often present late and may not receive proper perinatal and postpartum care because health workers are inadequately trained or do not have the equipment and supplies they need. Saving women’s lives requires that pregnancy complications are recognized early, and women who need additional care are quickly transferred to a higher level of care.

In this realm, I can look to work my colleagues have done in India and Mali and see that there are relatively low-cost interventions that can improve women’s lives. This includes working with nurse-midwives and traditional birth attendants to ensure they are fully equipped to recognize and refer women with pregnancy complications and to strengthen the referral network. IntraHealth and its partners can also collaborate more closely with communities to understand how to encourage healthy pregnancies, recognize symptoms of complications within the community, and consider launching projects such as expectant mothers’ shelters, which offer a safe waiting place for women to go to at the end of a pregnancy so they have easy access to the hospital if necessary. Additionally, ensuring all women and couples have access to their contraceptive of choice will go a long way to enabling women to choose if and when to get pregnant and avoid pregnancy-related complications. Finally, Dr. Chani and I also identified the need to train more health workers in neonatal resuscitation and infection control—critical actions in keeping newborns alive—and to work with our partners in Namibia to make sure clinics and health workers have the equipment and supplies they need, which can mean the difference between life and death in an emergency situation.