The second phase of trying to build spinal cord injury rehabilitation has clearly and brutally shown us the importance of the necessary first steps of the same. You soon realize the consequences of lack of knowledge about spinal cord injury care and rehabilitation, the absolute necessity of two hourly turnings and early mobilization. You also realize the strength of working in a team. The common focus on activity and the long term goal of return to life for each patient. Also each step is necessary to reach this goal. To lie in bed, as it is so obviously shown here in Botswana, gives difficult consequences for the patient and soon also for the staff. Pressure wounds, infections, contractures are reality that follows from not being turned regularly and not mobilized from bed. Reversed you are also convinced about the importance of rehabilitation when you see the impact of just getting out from bed once a day. Not the least for the mind. As acute hospitals often do Princess Marina lacks facilities to be active in. We all spend much time at the physio therapy department that is the location that offers most space and activities, we gather for training individually and in groups and we have also started with lectures for both out an in-patients. With continues rotation of nurses and doctors we understand that education of each patient is time well spent.

The difficult part with working at Princess Marina Hospital compared to our everyday life at Spinalis, besides lack of staff and teamwork, is lack of systems to work with. Maybe a cliché, but you learn to appreciate what you have. Wheelchairs after 4 weeks, shower chairs and beds after one, the apartments and houses adjusted after some months.. but still, adjusted. Of course an OT from Stockholm also has to adjust to the differences another country mean and use imagination and creativity, but still, with a spinal cord injury everything cannot be solved with garden chairs and old mattresses.  After a few months we although learned that some systems exists. Last month we had two important meetings. With Mr Wapapa at MVA, the Motor Vehicle Accident Found, and Mr Motingwa, the coordinator for people with disabilities at the office of the president. Mr Motingwa offered a positive attitude towards us and interest to cooperate, especially in issues on work rehabilitation. From Mr Wapapa we learned that MVA offers a generous insurance for the absolute majority of patients, injured in traffic, which can enable home adjustments, work rehabilitation and necessary technical aids. This surprisingly modern insurance change 3 years ago and gives us the opportunity to more easily assist newly injured persons with necessary equipment. This made it possible to have the first workshop with an south African technical aid company and try out wheelchairs for the patients.

It is those small and big steps that we remember through days at the ward.

The team, as it’s formed at the moment, existing of Occupational Therapist Beauty, Physio Therapist Sharon, Nurse Maria together with Inka, Tobias and Lisa, have now started to work with traumatic spinal cord injured patients at Princess Marina Hospital. The process to start working with such a project in Botswana could be somewhat frustrating we were told beforehand, time-consuming others said. Now when we look back on months of negotiation for the agreement, days at registration and immigration it seems as though it’s far away and that things went well. We are all working. Accept for Gunnel. This is another story. We hope and wish for the post office to find her last paper and that she finally will be allowed to join the team at the ward. She is so needed there although her current fabric of cushions is likely appreciated. Dr Katja came and went. Like a whirlwind trough the ward. With all her charm, drive, never ending energy and knowledge she is already missed by colleagues and patients here in Botswana.

Our new home far away from home offers reverse seasons and sitting here in the African winter, dry and with 26 degrees Celsius is confusing and so unusual to us. When the evening comes darkness is solid and temperature drops, as we never experienced temperature drops before, we are thankful that our part of town is not included in the regular power cuts we have been told about.

It works quite well after such a short time, we optimistically state. Although there are a number of problems to solve when two different cultures meet. Us Swedes with the constant urge to structure, our inability to take no for an answer, at least when it comes to the well of the patients, our habits from the Swedish system of care now trying to understand the structure of the Batswana system. How do we get to know which nurse at the ward is responsible for our patients today, when are the wounds dressed and by whom, which doctor is responsible, and at what times do patients eat? Likely important when do we eat and where?  What time do the team best use, the Swedish or Botswana time. After being here for a month the whole team can agree that concept of time differs, for good and for bad. Our clothes did not quite fit the Batswana dressing code although it was the nicest we have ever seen. Far away from wine-colored we have experienced in Sweden. Reprimanded by all those things we know so well about but that are turned upside down when in a new setting. Visiting hours, writing journals etc. We are learning, and also teaching. A constant give and take and we are all thankful that the project includes a long period of cooperation to build a new system of care and rehabilitation that we all hope for. Some could surely think we demand too much, but many agree to that changes are needed.

The Princess Marina Hospital is a governmental hospital where all the wards are separate one storey buildings, combined by wall-less corridors. We have two cubicles – rooms without doors –, one at female ortho and one at male ortho, a total of nine bed. Still they are not yet full. Which is good of course, but those who are in the same room might wonder why the others get so much care and attention. We also have a small office in male ortho and an activity room in female, yet to be furnished.

We have started with challenges in the ward to say the least. High injuries which demands appropriate technical aids that is lacking in Botswana and patients that in our opinion are in need for constant attention initially. Further many patients have great wounds that slow down rehabilitation and prevent us from training them to make the quick steps we would have liked to be able to show in the ward. Although we see changes even though small ones so far. We see hope, we see curiosity and sometimes, but only sometimes we see joy. A young man, with paraplegia, at first reluctant to join the team at the ward now listening to stories about what is possible in the future, being independent, driving a car, going to the toilet etc. Looking forward to seeing the commode chair that are somewhere in-between Johannesburg and Gaborone. Our equipment is stuck in customs. As far as we know. Even though he sometimes gives us his “what are you talking about-look” or express doubt by saying “I don’t think we´re at the same page here” we see the smile from time to time and it really compensates a lot of other headaches.

Outpatient clinic is running with 4 new patients each week. Most of them immediately scheduled for more appointments. We see the need for wheelchairs as a number one priority, and also training and encouragement to reach independence, the techniques for transfers, dressing and bowel and bladder management. The patients we meet express frustration about accessibility which is far from optimal in Sweden but so much worse here wherever you go in the city. Also there is a need for information about the spinal cord injury and empowerment. A rehab coach, we know for sure, will be a given success.

There are still a lot of practicalities to be solved and for us to learn how to manage them. Making copies for example.  We will never again complain about the machine at Spinalis in need for 10 minutes warming before use. We love that machine. Inka on a copying mission first learned that every single copying machine at the hospital was out of order. She went to the managing director (she goes there a lot, with long lists) and asked him what to do.” You can copy at the pharmacy, no problem”. Okay, Inka went to the pharmacy. There she was told she needed a code to the copy machine. “OK, where do I get that?” “Registration, administration building third floor”. Off to registration! At registration, “No, you cannot get a code but there is a man is going there now and he can copy for you.”  “But, I don’t have not the papers here right now, and how do I do it next time I want to copy?” The code finally was secretly given to Inka who went back to the pharmacy the next day. At the pharmacy another voice “No, you cannot copy even if you have the code, you must leave the papers in the registration and they will copy for you because we do not want everybody to run here”. Inka frustrated, with well tested patience, fed up with not having papers needed for outpatient clinic, finally allowed to copy, just this once. The rest of the papers are now left at registration. They say that you learn patience in Botswana!! And we are learning.