Anesthesia in Low Resourced Settings Near Misses and

Lessons Learned

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For the next generation
Matthew B. Brock-Utne
Tobias J. Brock-Utne
Anders C. Brock-Utne
Jasper L. Brock-Utne
Stefan S. Brock-Utne
Charlotte E. Brock-Utne
Foreword

Historically, the medical mission trip was the most common form of engagement in
Global Health by anesthesiologists. In generations past, “mission” had a different
meaning. Albert Schweitzer, a humanitarian and physician, won the Nobel Peace
Prize in 1952 largely for his philosophy, “Reverence for Life”. His most notable
work was the foundation of a hospital in Gabon in 1913, a hospital that has been
rebuilt twice, but still provides service and sees patients today.
Over time, Global Health has evolved into its own field of study and has largely
shifted focus towards building local capacity to strengthen healthcare systems
through education and research. Many Global Health experts have even called into
question the value and motivations of short-term, service-based “mission” work,
citing ethical considerations and neocolonialism.
However, if you ask the countless patients whose lives have been changed from
recto-vaginal fistula repairs when local surgeons do not exist, or the babies delivered
safely by foreign physicians, or the child who no longer suffers from malnutrition
after his cleft palate repair, then these mission trips receive resounding support. If
you ask the 50,000 patients seen each year at Albert Schweitzer hospital, one could
assume they support his mission.
Only when you work in a setting where resources are more constrained than your
own do you realize the vast amounts one can take for granted. We cancel cases if the
temperature and humidity are not perfect, while many operating rooms have open
windows, unreliable electricity and lack running water. Individual tourniquets used
for each and every patient can be substituted by tying the same latex glove around
the arms of the day’s patients. Disposable gowns, drapes and masks are reusable
cloth in other settings. Some anesthesia providers have never seen an end-tidal car-
bon dioxide waveform, and some EKG monitors use tiny needle electrodes. Oxygen,
air and suction are not piped through the walls of most facilities. In fact, medical air
is largely unavailable. Astonishingly, so is medical oxygen.
Using industrial oxygen instead of medical-grade oxygen for hypoxemic patients,
using tap water instead of distilled water for ventilator humidification systems,
using an adult blood pressure cuff on a paediatric patient – these are real dilemmas
faced daily by those working without the basic resources required for patient care.

vii
viii Foreword

Providers are forced to make choices between the ideal, the less than ideal and the
unthinkable, to get patients through surgery and critical illness. Although tough
choices often inspire innovation from which we all should learn, there are many
occasions where patient safety is compromised. Learning to maintain a narrow bal-
ance is the goal for any anesthesiologist working when resources are constrained.
The accounts in this book give historical context, exploring equipment most have
never seen, medications no longer available, and a time before vigilance for patient
safety with standard monitoring. In addition to practical learning points, this book
poses common ethical dilemmas still relevant in today’s global health practice. How
do you obtain informed consent with cultural awareness? What should be done to
prevent the donated equipment graveyards? What can we learn from traditional
medicine providers? Through thoughtful case discussions, readers are given fair
warning that challenges always arise when working in new settings, but solutions
are usually local. In rural practice, these dilemmas continue to arise, not only
abroad, but in our own backyards. For the anesthesiologists working in remote areas
with fewer resources, for the anesthesiologists providing clinical service in foreign
environments, for any anesthesiologist about to embark on a mission trip, this book
will provoke considerations you did not have previously. You will be more prepared.

Ana Maria Crawford, MD, MSc, FASA

Founder of the Division of Global Health Equity at Stanford University
Stanford, CA, USA
[email protected]
Map of Africa

AFRICA

Medi
Algiers te
rr
Tunis
an
Rabat
TUNISIA ean
Madeira Is. Sea
(PORTUGAL)
MOROCCO Tripoli

Canary Is. Cairo

(SPAIN)
ALGERIA
Laayoune LIBYA
EGYPT
Western
Sahara
Re
d
Se

MAURITANIA
a

CABO VERDE Nouakchott

MALI NIGER SUDAN ERITREA
Dakar CHAD
Praia SENEGAL Lake Khartoum Asmara
Niamey
GAMBIA Bamako Chad
den
Banjul BURKINA FASO lf of A Socotra
N'Djamena DJIBOUTI G u (YEMEN)
Bissau Ouagadougou Djibouti
GUINEA-BISSAU GUINEA
G NIGERIA
B ENIN

Conakry ETHIOPIA
TOG O

CÔTE- Abuja
H

Freetown
AN

SOUTH
A

SIERRA D'IVOIRE Addis Ababa

CENTRAL
LI
A

LEONE Yamoussoukro Accra

AFRICAN REPUBLIC SUDAN
Monrovia Porto
A
e

LIBERIA Novo CAMEROON Bangui Juba

M
om

Abidjan
SO
L
Malabo Yaoundé Lake
EQUATORIAL GUINEA UGANDA Turkana
Principe Lake
Albert Mogadishu
SAO TOME AND PRINCIPE São Kampala
Tomé Libreville KENYA
GO

São Tomé
GABON DEMOCRATIC RWANDA Nairobi
N

Annobón
O

C REPUBLIC
(EQUATORIAL GUINEA)
OF THE
Kigali Lake
Victoria INDIAN OCEAN
Brazzaville Bujumbura
CONGO BURUNDI
Kinshasa Lake Pemba Amirante Is. Victoria
Cabinda Tanganyika Dodoma
(ANGOLA) Zanzibar
A T L A N T I C UNITED REPUBLIC OF SEYCHELLES
Ascension
Luanda
TANZANIA Providence Is.
(UK) Aldabra Is.
Farquhar Is.
O C E A N Lake
Nyasa Moroni Agalega Is.
ANGOLA COMOROS (MAURITIUS)

Lilongwe Mayotte Is.

ZAMBIA MALAWI (under French
admin.) Tromelin
St. Helena Lusaka UE R (FRANCE)
IQ
A

(UK) Cargados
B
C

Lake Harare Carajos

AS
M

Kariba Antananarivo MAURITIUS

ZIMBABWE
ZA

AG

Port Louis
MO

NAMIBIA
MAD

Réunion
BOTSWANA (FRANCE)
Windhoek Gaborone
Pretoria
Maputo
Mbabane
ESWATINI
Bloemfontein
Maseru
SOUTH LESOTHO
AFRICA
Cape Town

The boundaries and names shown and the designations used

on this map do not imply official endorsement or acceptance
by the United Nations.
0 500 1000 km
Final boundary between the Republic of the Sudan and the
Republic of South Sudan has not yet been determined.
0 500 mi

Based on UN map Department of Field Support

Geospatial Information Section (formerly Cartographic Section)

ix
African Countries Are Mentioned
in Alphabetical Order in the Text

I am sure you will be surprised that there are 54 independent countries in Africa.
There are also other countries outside of Africa that are mentioned in the case stud-
ies. They are included separately at the end. The information about all these coun-
tries includes its population, language and religion.

Africa

Algeria

Algeria is a North African country with a Mediterranean coastline and a Saharan

desert interior. Many empires have left legacies here, such as the ancient Roman
ruins in seaside Tipaza. In the capital. Algiers, Ottoman landmarks are seen from
circa 1612. Population: 42 million. Official language Arabic. Religion: Islam.

Angola

Angola is a Southern African nation whose varied terrain encompasses tropical

Atlantic beaches, a labyrinthine system of rivers and a Sub-Saharan desert that
extends across its southern border into Namibia. The country’s colonial history is
reflected in its Portuguese-influenced cuisine and its landmarks including Fortaleza
de São Miguel, a fortress built by the Portuguese in 1576 to defend the capital,
Luanda. Population: 31 million. Official language: Portuguese – spoken by 80% of
the population, but there are six other African languages spoken. Religion: Christian.

xi
xii African Countries Are Mentioned in Alphabetical Order in the Text

Benin

Benin is a French-speaking West African nation. It is a birthplace of the vodun (or

“voodoo”) religion and home to the former Dahomey Kingdom from circa
1600–1900. In Abomey, Dahomey’s former capital, the Historical Museum occu-
pies two royal palaces with bas-reliefs recounting the kingdom’s past and a throne
mounted on human skulls. To the north, Pendjari National Park offers safaris with
elephants, hippos and lions. Population: 12 million. Official language: French, but
there are 55 national languages. Religion: 27.7% Muslim, 25.5% Roman Catholic,
13.5% Protestant, 11.6% Vodun, 9.5% of other Christian denominations and 12.2%
of others or none.

Botswana

Botswana, a landlocked country in Southern Africa, has a landscape defined by the

Kalahari Desert and the world-famous Okavango Delta. The latter becomes a lush
animal habitat during the seasonal floods. The massive Central Kalahari Game
Reserve, with its fossilized river valleys and undulating grasslands, is home to
numerous animals including giraffes, cheetahs, hyenas and wild dogs. The capital is
Gaborone. Population: 2.2 million. Official language: English. There are, however,
20 other languages spoken. Religion: Officially, Botswana is said to be a Christian
country, although the number of practicing Christians is estimated at only around
20% of the population. Many people still maintain dual religious practices between
Christianity and traditional religious worship.

Burkina Faso

Burkina Faso, officially the People’s Democratic Republic of Burkina Faso, is a

small landlocked country in West Africa. A former French colony, it gained indepen-
dence as Upper Volta in 1960. The name Burkina Faso, which means “Land of
Incorruptible People,” was adopted in 1984. The capital Ouagadougou is in the cen-
tre of the country and lies about 500 miles (800 km) from the Atlantic Ocean.
Population: 21 million. Religion: 50% of the population is Muslim. Official language
is French but most people speak Mòoré and Fula as well as the African language.

Burundi

Burundi is a country in east-central Africa, south of the Equator. This landlocked coun-
try is one of the few countries in Africa whose borders were not determined by colonial
rulers. The vast majority of Burundi’s population is Hutu, traditionally a farming
African Countries Are Mentioned in Alphabetical Order in the Text xiii

people. Power, however, has long rested with the Tutsi minority, which historically has
controlled the army and most of the economy, particularly the lucrative international
export of coffee. Few real cultural differences are distinguishable between the two
peoples, and both speak Rundi (Kirundi). Population 11 million; 60% of the population
is Roman Catholic; Official language is Rundi (Kirundi), a Bantu language that is the
standard medium of communication throughout the country and French.

Cape Verde

Cabo Verde, also called Cape Verde, country comprises a group of islands that lie
385 miles (620 km) off the west coast of Africa. Praia on Santiago is the capital. The
largest port in the islands is located at Mindelo on Sao Vicente. Its deepwater har-
bour accommodates sizable vessels and has been used as a fuelling station since the
19th century. Population: 550,000. Official language: Portuguese. Religion: 80%
Roman Catholic

Cameroon

Cameroon, on the Atlantic, is a Central-West African country of varied terrain and

wildlife. Its inland capital, Yaoundé, and its biggest city, the seaport Douala, are
transit points to ecotourism sites as well as beach resorts like Kribi – near the Chutes
de la Lobé waterfalls, which plunge directly into the sea. Population: 26.5 million.
Official language: both English and French. Religion: 80% Christian.

Central African Republic (CAR)

The Central African Republic is a landlocked country in Central Africa. Armed

groups continued to commit serious human rights abuses, expanding their control to
an estimated 70% of the country, while the central government, led by President
Faustin-Archange Touadéra, controlled the capital, Bangui. Population: 4.6 million.
Official language: French and Sango. There are over 72 African languages. Religion:
Christion 90%; Muslim 10%.

Chad

A largely semi-desert country, Chad is rich in gold and uranium and stands to ben-
efit from its recently acquired status as an oil-exporting state. In 2003, it completion
of a $4bn pipeline linking its oilfields to terminals on the Atlantic coast. Chad’s
xiv African Countries Are Mentioned in Alphabetical Order in the Text

post-independence history has been marked by instability and violence, stemming

mostly from tension between the mainly Arab-Muslim and the predominantly
Christian. Poverty is rife, and health and social conditions are poor. Population: 15.5
million. Official language: French and Arabic. Religion: 51.8% practicing Islam,
43.8% practicing some form of Christianity, and the remaining 4.4% being atheist.
Within the Muslim community, 58% are Sunni, 11% are Shia, 4% are Ahmadi and
23% are nondenominational.

Comoros

The Comoros is a volcanic archipelago off Africa’s east coast, in the warm Indian
Ocean waters of the Mozambique Channel. The nation state’s largest island, Grande
Comore (Ngazidja), is ringed by beaches and old lava from the active Mt. Karthala
volcano. Around the port and medina in the capital, Moroni, are carved doors and a
white colonnaded mosque, the Ancienne Mosquée du Vendredi, recalling the
islands’ Arab heritage. Population: 850,000. Official Language: Comorian, French
and Arabic. Religion: 98% are Sunni Muslims.

Congo, Democratic Republic of the Congo

The Democratic Republic of the Congo, also known as DR Congo, the DRC, DROC,
Congo-Kinshasa or simply the Congo, is a country located in Central Africa. It was
formerly called Zaire. It is, by area, the largest country in sub-Saharan Africa, the
second-largest in all of Africa, and the 11th largest in the world. Population: 84 mil-
lion. Official Language: French. Religion: Some three-fourths of the population is
Christian. Adherents of Roman Catholicism account for about one-third of the
country's Christians. The Protestant community includes members of the Evangelical
Church of the Congo.

Congo, Republic of the Congo

The Republic of the Congo, also called Congo-Brazzaville, is a central African

nation with rainforest reserves that are habitats for gorillas. Its capital city,
Brazzaville, lies across the Congo River from Kinshasa, the capital of neighbouring
Democratic Republic of the Congo. Brazzaville’s highlights include traditional craft
markets and the mid-20th-century Basilique Sainte-Anne, with a green-tiled roof
and spire. Population: 5.6 million. Official language: French. Religion: Christian
with 12% Muslims.
African Countries Are Mentioned in Alphabetical Order in the Text xv

Cote d'Ivoire (Ivory Coast)

Côte d'Ivoire is a West African country with beach resorts, rainforests and a French-­
colonial legacy. Abidjan, on the Atlantic coast, is the country’s major urban centre.
Its modern landmarks include La Pyramide and St. Paul's Cathedral, a swooping
structure tethered to a massive cross. North of the central business district is the
Banco National Park, a rainforest preserve with hiking trails. Population: 25 mil-
lion. Official Language: French. Religion: Islam 44 % and Christian 34 %. The rest
follows traditional African religions.

Dijbouti

Djibouti, on the Horn of Africa, is a mostly French- and Arabic-speaking country of

dry scrublands, volcanic formations and Gulf of Aden beaches. It’s home to one of
the saltiest bodies of water in the world, the low-lying Lake Assal, in the Danakil
Desert. The nomadic Afar people have settlements along Lake Abbe, a body of salt-
water featuring chimney-like mineral formations. Population: 1 million. Official
language: Arabic and French. Religion: 94% Sunni Muslims.

Egypt

Egypt, a country linking northeast Africa with the Middle East, dates to the time of
the pharaohs. Millennia-old monuments sit along the fertile Nile River Valley,
including Giza's colossal Pyramids and Great Sphinx as well as Luxor's hieroglyph-­
lined Karnak Temple and Valley of the Kings tombs. The capital, Cairo, is home to
Ottoman landmarks like Muhammad Ali Mosque and the Egyptian Museum, a trove
of antiquities. Population: 99 Million. Official language: Egypt-Arabic. Religion:
Islam (Shia).

Equatorial Guinea

Equatorial Guinea is a Central African country comprising the Rio Muni mainland
and 5 volcanic offshore islands. Capital Malabo, on Bioko Island, has Spanish colo-
nial architecture and is a hub for the country’s prosperous oil industry. Its Arena
Blanca beach draws dry-season butterflies. The tropical forest of the mainland’s
Monte Alen National Park is home to gorillas, chimpanzees and elephants.
Population: 1.4 million. Official language: French, Spanish and Portuguese Religion:
Christian (90 %).
xvi African Countries Are Mentioned in Alphabetical Order in the Text

Eritrea

The Italians created the colony of Eritrea in the 19th century around Asmara and
named it with its current name. After World War II, Eritrea was annexed to Ethiopia.
In 1991, the Eritrean People’s Liberation Front defeated the Ethiopian government.
Population: 3.5 million. There is NO official language. English and Italian are also
widely understood, but there are many Eritrea languages, like Tigrinya. Arabic and
English predominate in commerce and national business. Religion: 60% Christian
and 35% Islam.

Eswatini (formerly Swaziland)

Eswatini is a landlocked monarchy in Southern Africa. It is bordered by Mozambique

to its northeast and South Africa to its north, west and south. It is one of the smallest
countries in Africa. The population is 1.1 million and is composed primarily of
ethnic Swazis. The language is Swazi, but most speak English. Religion: Traditional
and Christian.

Ethiopia

Ethiopia, in the Horn of Africa, is a rugged, landlocked country split by the Great
Rift Valley. Ethiopia is a predominantly agricultural country – more than 80% of the
population lives in rural areas. With archaeological finds dating back more than 3
million years, it’s a place of ancient culture. Among its important sites are Lalibela
with its rock-cut Christian churches from the 12th to 13th centuries. Population: 115
million. Official language: Ethiopia has 83 different languages with up to 200 dif-
ferent dialects spoken. The largest ethnic and linguistic groups are the Oromos,
Amharas and Tigrayans. Religion: Orthodox 43.5%, Muslim 33.9% and
Protestant 18.5%.

Gabon

Gabon, a country along the Atlantic coast of Central Africa, has significant areas of
protected parkland. The forested coastal terrain of its famed Loango National Park
shelters a diversity of wildlife, from gorillas and hippos to whales. Lopé National
Park consists of mostly rainforest. Akanda National Park is known for its man-
groves and tidal beaches. It was to this country Dr. Albert Schweitzer settled in
1913. He wrote the book called: “Reverence for life”, for which he received the
African Countries Are Mentioned in Alphabetical Order in the Text xvii

1952 Nobel Peace Prize. Actually, I (JGBU) was a little boy seeing him, in on the
balcony of the City Hall, in Oslo when he got the Peace Prize. What an example he
was to us all. Population: 2.1 million. Official language: French. Religion: Roman
Catholics account for about two-fifths.

Gambia

Gambia is a small West African country, bounded by Senegal, with a narrow Atlantic
coastline. It’s known for its diverse ecosystems around the central Gambia River.
Abundant wildlife in its Kiang West National Park and Bao Bolong Wetland Reserve
includes monkeys, leopards, hippos, hyenas and rare birds. The capital, Banjul, and
nearby Serrekunda offer access to beaches. Population: 2.2 million. Official lan-
guage: English. Religion: Muslim 90%.

Ghana

Ghana (Warrior King) is a country located along the Gulf of Guinea an Atlantic
Ocean in West Africa. The first permanent state in the territory of present-day Ghana
dates back to the 11th century. Beginning in the 15th century, the Portuguese
Empire, followed by numerous other European powers, before the British ultimately
established control of the coast by the late 19th century. Ghana became independent
in 1957, Population: 30 million. Official language: English. Religion: Christian 70%.

Guinea-Bissau

Guinea-Bissau is a tropical country on West Africa’s Atlantic coast that’s known for
national parks and wildlife. The forested, sparsely populated Bijagós archipelago is
a protected biosphere reserve. Its main island, Bubaque, forms part of the Orango
Islands National Park, a habitat for saltwater hippos. On the mainland, the capital,
Bissau, is a port with Portuguese colonial buildings in its old city centre. Population:
1.8 million. Official language: Portuguese. Religion: Christian.

Ivory Coast

In 1960 France granted independence under President Felix Houphouet-Boigny. He

held power until he died in 1993. From 2002 to 2007, Civil war effectively splits the
country into Muslim rebel-held north and government-controlled Christian south.
xviii African Countries Are Mentioned in Alphabetical Order in the Text

Post-election 2010, left 3,000 people dead and 500,000 displaced. In 2016 Al-Qaeda
jihadists attack the beach resort of Grand Bassam, near Abidjan, killing 18 people.
Population: 25 million. Official language: French. Religion: Islam, Christian and
indigenes beliefs.

Kenya

Kenya is a country in East Africa with coastline on the Indian Ocean. It encom-
passes savannah, lakelands, the dramatic Great Rift Valley and mountain highlands.
It’s also home to wildlife like lions, elephants and rhinos. From Nairobi, the capital,
many National Parks can be accessed. From many, you can view Tanzania's 5,895
metre Mt. Kilimanjaro. Population: 51 million. Official language: Swahili and
English. Religion: Christian 85% and Islam 10%.

Lesotho

Lesotho, a high-altitude, landlocked kingdom encircled by South Africa, is criss-

crossed by a network of rivers and mountain ranges including the 3,482 metre high
peak of Thabana Ntlenyana. On the Thaba Bosiu plateau, near Lesotho’s capital,
Maseru, are ruins dating from the 19th-century reign of King Moshoeshoe I. Thaba
Bosiu overlooks iconic Mount Qiloane, an enduring symbol of the nation’s Basotho
people. Population: 2.1 million. Official language: Sesotho and English. Religion:
Christian 90%.

Liberia

Liberia is a country in West Africa, bordering Sierra Leone, Guinea and Côte
d'Ivoire. To the west is the Atlantic coast. Here you find the capital city of Monrovia
(named after the US President Monroe). In the city is the Liberia National Museum,
with its exhibits on national culture and history Liberia was founded by free people
of colour from the United States. They created the American Colonization Society
(ACS). In 1847, the ACS encouraged Liberia to declare independence, as the orga-
nization could no longer support the colony against territorial incursions by the
neighboring British and French. The United States declined to act on requests from
the ACS to make Liberia an American colony or to establish a formal protectorate
over Liberia, but it did exercise a “moral protectorate” over Liberia, intervening
when European powers threatened its territory or sovereignty. The Republic of
African Countries Are Mentioned in Alphabetical Order in the Text xix

Liberia was created on July 26, 1847. The Virginia-born Joseph Jenkins Roberts
was the nation’s first president. Population: 4.8 million. Official language: English.
Religion: Christian 85%.

Libya

Libya, officially the State of Libya, is a country in the Maghreb region in North
Africa, bordered by the Mediterranean Sea to the north, Egypt to the east, Sudan to
the southeast, Chad to the south. Since 2015 a second civil broke out, with parts of
Libya split between the Tobruk and Tripoli-based governments, as well as various
tribal and Islamist militias. Population: 6.7 million. Official language: Arabic.
Religion: Islam with 97% Sunni.

Madagascar

Madagascar is the world second largest island in the world in the Indian Ocean. It is
the biggest producer of vanilla in the world. It is approximately 400 km off the coast
of East Africa. Population: 27 million. Official language: Malagasy and French.
Religion: Christian 41% and Islam 7%.

Malawi

Malawi, a landlocked country in southeastern Africa, is defined by its topography of

highlands split by the Great Rift Valley and enormous Lake Malawi. The lake’s
southern end falls within Lake Malawi National Park – sheltering diverse wildlife
from colourful fish to baboons – and its clear waters are popular for diving and boat-
ing. Population: 18.1 million. Official language: English. Religion Christian: 77%
and Islam 15%.

Mali

Mali, officially the Republic of Mali, is a landlocked country in West Africa. Mali
is the eighth-largest country in Africa, with an area of just over 1,240,000 square
kilometres. The population of Mali is 19.1 million. 67% of its population was esti-
mated to be under the age of 25 in 2017. Its capital is Bamako. Official language:
French. Religion: Islam 95%.
xx African Countries Are Mentioned in Alphabetical Order in the Text

Mauritania

Mauritania is an Islamic in Northwest Africa. It is the eleventh largest sovereign

state in Africa and is bordered by the Atlantic Ocean to the west. Population: 4.4
million. Official language: French. Religion: Islam 100%.

Mauritius

Mauritius, an Indian Ocean island nation, is known for its beaches, lagoons and
reefs. The mountainous interior includes Black River Gorges National Park, with
rainforests, waterfalls, hiking trails and wildlife like the flying fox. Population: 1.2
million. Official language: Creole 84%. Religion: Hindu 50%, Christian 33% and
Islam 16%.

Morocco

Morocco is a North African country bordering the Atlantic Ocean and the
Mediterranean Sea. It is distinguished by its Berber, Arabian and European cultural
influences. Casablanca is the largest city. Population: 36 million. Official language:
Arabic. Religion: Islam 73 %.

Mozambique

Mozambique is a southern African nation whose long Indian Ocean coastline is dot-
ted with beaches and offshore marine parks. The fishing is incredible as landmines
have prevented fishing from the beaches. In the Quirimbas Archipelago, a 250 km
stretch of coral islands, mangrove-covered Ibo Island has colonial-era ruins surviv-
ing from a period of Portuguese rule. Population: 29.5 million. Official language:
Portuguese. Religion: Christian 58% and Islam 19%.

Namibia

Namibia is a country in southwest Africa and is distinguished by the Namib Desert

along its Atlantic Ocean coast. The country is home to diverse wildlife, including a
significant cheetah population. The capital, Windhoek, and coastal town Swakopmund