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SCOTTISH LIVINGSTONE HOSPITAL, MOLEPOLOLE

When Dr Peter Shepherd arrived in Molepolole in 1931, he set three tasks for the United Free Church of Scotland Mission: to establish the church, to heal the sick and, in modern terminology, to localise. He wrote, "There's fifty years' work for us to do".

Present indications are that the Hospital will be taken over by the government in 1975, six years before the fifty are up. Opened in 1934 and named after the first Scottish missionary in Molepolole (the Dr Livingstone), the Hospital has since Dr Shepherd's departure in 1948 been under the Rev Dr Alfred Merriweather. Dr Merriweather is a household name in Botswana; he was for five years Speaker first of the Legislative Council and then after Independence of the first National Assembly, and in 1972 he was awarded the Presidential Order of Honour. The matron and sister tutor, also from Scotland, have been at the Hospital almost as long as Dr Merriweather. In those days it was usual to sign thirty-year contracts.

The Hospital has 169 beds and runs four permanently staffed clinics in the Kweneng District. Monthly or more frequent visits are made from these clinics to 12 other villages (see Kopong Clinic report – No 21), while visits from the Hospital itself are made monthly or quarterly to villages, four of them up to 180 miles away on the track through the Kalahari. The total number of outpatient first-visits to the Hospital and permanent clinics in 1972 was 45,000. The Hospital runs a training school for registered nurses, midwives and enrolled nurses. The annual budget is of the order of R86,000, of which about 43% comes from the government. Assets, including the clinics and eight vehicles, were valued in 1972 at nearly R295,000.

Aid from Christian agencies has been a major contribution to the Hospital's development. Between 1966 and 1970 over R60,000 was received from the World Council of Churches (Inter-Church Aid) for nurses' quarters, renovations and a new Outpatients Dept. Most of this came from Bread for the World, with the Finnish Lutheran Church another donor. (In the same period Oxfam gave R14,500 for vehicles, a children's ward and running expenses for two clinics). For convenience, aid channelled through the BCC is discussed under the headings of: CSC; commodities; sewage.

A. BCC Christian Service Committee

Listed here are the small disbursements made from the CSC's discretionary village development fund:-

a) November 1968 – R428.03 for a borehole pump and engine. With the building expansion at this time the Hospital's water needs rose, and a fourth borehole was drilled free of charge by the Geological Survey Dept. It proved to have a very high yield – 2,000 g.p.h. – higher than the other three combined. The cost of a Mono pump, twin Lister engine and piping installed by Water Affairs was R473.85. A grant from Christian Aid of £250 covered most of this (the rolling fund was only launched in 1970).

1 b) October 1971 – R85.80 for blankets. The Hospital had somehow missed its share of one of the periodic shipments of blankets from the US, organised by Church World Service (CWS). New blankets were needed for the 32-bed medical ward so a grant was made and the blankets purchased in South Africa.

c) September 1972 – R752.20 for a return airfare to Edinburgh for Staff- Nurse Harriet Rampa (grant from Christian Aid). S/N Rampa did a year's course in Hospital Management and Theatre Technique at Edinburgh Royal Infirmary, having been selected to be the Hospital's first Botswana theatre sister. For various reasons her place on the course was secured at short notice, and the CSC's ability to respond promptly meant not only that she got to Edinburgh but that she arrived in time for the start of the course. Her expenses while there were met by the united Free Church. A letter she wrote to the Development Organiser in November 1972, after flying from early summer in Botswana to a Scottish autumn, gives an idea of her first impressions:

"... The place is cold, overcrowded and historical of course ... I must say Scottish people are traditional, just like Botswana. I am settling well in this place and enjoying my course though very high powered ... thank you for making my coming here a success. I never thought it would be possible for me to go abroad for studies".

d) January 1973 – R350 for mosquito netting for the children's ward: 42 beds and cots. The mosquito problem has been aggravated in recent years by the worsening sewage situation but the area seems basically to favour them. While malaria is rare this far south, it does not help children whose resistance is already low to be attended night and day by a thirsty swarm. The nets were made up by ladies from the British High Commission and by a local lady paid by the latter. Apparently it is policy for British embassies to adopt a charity in their host country and the Hospital has the good fortune to be the Botswana one. The small balance of the grant went towards general expenses.

B. Commodities

Since 1968 CWS has been channelling material aid to Botswana. The main supplies shipped are medical and educational/training. By December 1972 this aid had reached a total value of about R415, 000 ($591,629). The Hospital has benefitted from this system along with other hospitals, as medical supplies are generally distributed through the government Central Medical Stores. Some shipments, however, have been designated for this hospital. Both are included here:-

1) Measles vaccine – Lengthy and inconsistent correspondence between the Development Organiser and the Depts of Health and of Development Planning has failed to establish (a) whether measles is epidemic or endemic in Botswana, 2) Whether or not it is virulent and; 3) Whether there is finance and storage space to keep stocks of vaccine on hand. One permanent secretary wrote,

2 "One wonders if it might not be sound policy to have reserve stock ... to use in the spring when the first cases occur", but the other stated, "Basically measles is not a major health problem".

While the debate goes on, children are vulnerable and mortality is high, some villages being worse hit than others. Deaths are due both to complications such as pneumonia and to the disease itself, which though not always virulent has an ally already in the field in malnutrition. Dr Merriweather reports that in his experience an outbreak occurs every two years. CWS sent 3,000 doses in 1969; 2,000 went to Mahalapye to check the southward spread of an outbreak that began in Francistown in June 1968, and 1,000 went to Molepolole. In August 1970 another emergency appeal went to CWS. This time they were unable to respond despite efforts to organise something through the manufacturers, UNICEF and the US Army. It seems a curious strategy to depend wholly and at short notice on a donor which is itself dependent on the goodwill of other agencies. In 1971 CWS was more successful. A Medical Officer in one centre wrote,

"The vaccine was given to children between 9 and 24 months ... We were very grateful for this vaccine which we hope will postpone the next epidemic. But most of all we hope for a regular supply ... so that we can immunise all babies as they reach the age of 10 months ... In this way we would hope to postpone epidemics ... until the children in the district have reached a better nutritional level". b) Sewing-machines – Three of the ten machines which arrived in January 1972 were delivered to Molepolole for use in the Hospital's occupational therapy section (2) and the nurses' home (1). Machines and/or small grants for working capital have been given to several hospitals for occupational therapy, and they are therefore considered together in one report (No 63). c) Medical supplies – channelled through CWS by the United Methodist Church: 17 x 80lb cartons in August 1972, and 25 in February 1973. Contents: drugs, linen and bandages. d) BCG vaccine – distributed to all hospitals in September 1972. e) Medical textbooks – from the Planned Parenthood Federation of the US, for the nurses’ school: 1 x 160-lb carton in December 1972. f) Most recently the Hospital has shared in another large consignment of blankets. These commodities are normally either not obtainable through the Medical Stores or, in the case of a mission hospital, are debited against the government grant-in-aid. Thus, they always represent cash saving for a mission hospital and sometimes also a sole source of supply

C. Sewage

The Hospital now extends over 16 acres on the summit of a rocky rise at the eastern end of the village. Like other mission hospitals, its development had preceded piece- meal as needs were recognised and funds were found. By 1968 it had become obvious, especially during the summer months, that the un-coordinated sewage disposal system was no longer adequate, in fact in the judgement of the Medical Officer of Health, "a serious health hazard". The percolation trenches had ceased

3 functioning, septic tanks were broken or clogged, and what reticulation there was, was ejecting raw sewage out on to the hill just below the Hospital. The danger to health was from the ready-made mosquito breeding grounds – malaria has been known here – and the possible pollution of the water supply.

In consultation with the government sewage engineer, a plan for a basic drainage system feeding into oxidation ponds was drawn up and submitted through the BCC to Inter-Church Aid in April 1969. The cost was R6,050. There was a prompt response from Christian Aid, which in August undertook to finance the whole project. However, on the advice of the Hospital architects Dr Merriweather then asked a firm of consultant engineers to make a detailed survey of the Hospital and draw up a comprehensive sewage plan. This was duly done; the new plan was costed by a contractor at R23,000 and the consultants sent in their own fee of R2,000. Christian Aid, to whom Dr. Merriweather then wrote, were unable to quadruple their commitment and uncertain about helping with the consultants' fee, since it appeared the scheme had now changed drastically in conception. In fact, the original plan had been kept modest because - a) It was thought likely to attract finance sooner, b) It sufficed to take the immediate strain off the existing system, c) It represented a first phase of what could later, when more funds became available, be made more elaborate and extensive.

The main factors that had changed were the urgency with which, in technical and medical opinion, a completely new system had to be installed; and the need, resulting from the survey, for deeper, longer and therefore more expensive trenches through the rock than were first thought necessary. In December 1970 the R6,083 from Christian Aid arrived and Dr. Merriweather used part of it to pay the consul- tants' bill, which he had succeeded in reducing to R1,500. At the same time he submitted a revised application to the BCC for an additional R29,200. This was forwarded to Geneva in March 1971. As time went on and no agency responded, it was decided in late 1972 to proceed with a version of phase I on a budget of R5,294, represented by the remainder of the Christian Aid grant (R4,583) plus interest on this on deposit (R711).

The new plan – Mark 3, so to speak – has been drawn up and largely completed under the supervision of the government assistant sewage engineer, Mr D. Wright, who has performed a remarkable feat of cost-cutting. The number of ponds is back to one, from three, and this has been re-sited so that (a) it is no longer near the boreholes, which removes the need for sealing, and (b) it is closer to the Hospital on a gentler slope of the hill, which has lessened the amount of excavation needed to place the drainage pipes at a proper gradient through the rock. Mr Wright has used his good relations with local contractors and suppliers, armed with the absolute cost-cutting constraint, to arrange reductions in hire and delivery charges of up to 40%. Because of the pressure of official work, he has used his own time on the project and he has reduced the Mark 2 (consultants') plan to its essentials, which are: a 6-inch bitumen pipe 400 yards long laid at a depth of 3.5 ft. along the back of the Hospital, collecting the effluent, i.e. the semi- stabilised overflow, from the nine septic tanks belonging to the main buildings and leading into a scooped pond 87 yds x 63 yds x and about 4.5 ft. deep. 'Extras' such as the pipe to the Outpatients Dept. were shelved.

4 The budget was as follows:-

Labour 800 Pipes 1,200 Manholes (12 @ R40) 480 Adjustments to pumps 50 Tools and protective clothing 300 Machinery (bulldozer) 1,250 Travel 150 Sledge, with tank and suction pump for septic tank cleaning 500 Sub-total 4,730 Contingencies – 10% 470 Total 5,200

As at 31.7.73 about two-thirds of the trench had been dug and the pond was beginning to take shape. The trench was being hacked out of the rock by hand by a team of men under the Hospital's maintenance engineer, Mr. M Powell. The job was expected to be complete by the end of September and the whole system commissioned by December.

Meanwhile, funds were beginning to come in for the project from donor agencies. On 29th March this year (1973) the Development Organiser passed on R3,894.03 to Dr. Merriweather from Kirkens Nodhjelp (Norway), and on 9th July R5,102.36 from Christian Aid and R1,388.95 from the New Zealand Council of Churches (their first grant to Botswana), making a total of R10,385.34. Messrs. Wright and Powell (Dr. Merriweather was away) were agreed that this would provide adequate finance for a modified phase II. The priorities now, as Mr. Wright sees them, are:

1) A more detailed survey of the Hospital buildings, with particular attention to levels. At least one septic tank is known to be wrongly positioned;

2) purchase of a proper septic tank emptying unit;

3) repairing or replacing broken plumbing and septic tank walls;

4) Linking up residential buildings, the administration and outpatient blocks and the dispensary to the system now being built. An additional cost will be Mr. Wright's own services, since on completion of his government contract he intends to set up his own sewage design and construction firm.

The conclusion might be, all's well that ends well. The hold-ups in this project have been no one's fault nor have they caused any great harm beyond giving the mosquitoes a year or two's grace. Even the rather costly survey is regarded as a pre-requisite for the scheme finally implemented. It is in fact the only known survey of the Hospital. It remains now to cost phase II and notify Inter-Church Aid as to whether further funds are needed.

August, 1973

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