Saturday 20 July 2013

05. Green Shoots

05. Green Shoots
21st July 2013

A newsflash on my nutrition: There has been a touching response to my harrowing, muscle-by-muscle account of the transition from alpha-male silverback into pygmy marmoset, occasioned by eating too healthily. (Perhaps I express it too strongly when I say ‘touching’. On reflection, perhaps ‘derisive’. Or ‘absent’.) For those who could not have borne the return to Coventry of a withered remnant, mockingly draped in Laurence’s skin, I bring good news.
Dan.

Dan Towie is Sion’s friend – a doctor from England – who has come to stay with us for a couple of weeks, to check out Africa, and to be there for Sion. (You would be forgiven for thinking, “But Laurence is there for Sion, surely? Is Sion not refreshed to the very marrow by Laurence’s admirably detailed and delightfully meandering reminiscences of his (rather more impressive) experience of the same emotional nadir? Does Sion not follow Laurence around, in trembling and breathless anticipation, hoping for yet more of his robustly delivered snippets of advice and instructions, which so readily fill and soothe the hurting places in the inner soul, displacing all anxiety and uncertainty?” You’d be forgiven, eventually, for thinking that.) Anyway, Dan is here, and completes the spectrum of cooking talent represented in our African home.

At the left-hand end of the spectrum is myself, who is to cooking what Mother Theresa was to basketball.

Considerably to the right of the centre of the spectrum lies Sion, a Tim Henman of the basting pan. Our compost heap is a veritable Henman’s Hill.

But, in a spectacular metaphorical leap, the Kaiser of the Kitchen is Dan. Vegetables delight in obeying him, yielding their rough and uncompromising outer antipathy to reveal their inner acquiescence. Spices dance alluringly at his bidding. Even fruits, putting aside ancient enmities, clamour around with legumes and nightshades, waiting to be squeezed, sliced or shredded into masterly culinary victory. The first night – Tortilla. Protein!! Filling! Delicious! I felt the life creep back into the pecs and six-pack, which so humbly lie a variable distance below the surface. The second night, Vegetable Curry, with Spiced Soy-Bean Dhal. Soy beans, I would like to remind you, come in sacks, and I had no more considered them part of my nutritional come-back than junk mail. Then on Thursday night, Derren-Browning an unpromising assortment of things-that-used-to-grow, he flourished before us Huevos Rancheros, Guacamole and Crushed Chili Sweet Potato! I mean, real Guacamole! How is this possible!?! (Actually, having watched him, I am pleased to be able to report the recipe: Take squashy greenish-purple things; flaky white golf-ball things which the previous occupants had left behind; hot crinkly red things that are rubbish in Nutella sandwiches; squeezes of what I had taken to be last year’s quinces; and white salty stuff from a cup labelled ‘salt’; do stuff with it; and suddenly, you have Guacamole.)

The nutritional recuperation came as a welcome response to the depressing collection of where-we-are-ness on Tuesday. Before judging too harshly, bear in mind the perspective of a rural African villager. Not much more than one hundred years ago in rural Tanzania, there were lions and TB and sleeping sickness and malaria and tetanus and dysentery and hookworm and warring tribes and obstructed labour and colonial oppression and failed crops and droughts and a complete absence of health care; all in the context of scraping around to survive long enough to hope to see one generation, for the most part. Death was like a weed, finding its way into every corner. This has changed only slowly, and anyone foolish enough to want to tug out every injustice, and take a scythe to all inadequacies, will find himself tired, and the roots barely harmed. So it is that a rural mission hospital can be overwhelmed if it aspires to perfection – or even, so it can seem, to proactivity. That is a small step from finding itself reacting, slowly, inadequately, only enough to stay where it is. This is not laziness or badness, it is simply a place on the road from the nineteenth century to the twenty-first.

And so on Tuesday morning, when Sion had been off for the weekend and the Monday, (among a number of other depressing incidents in the day), he experienced:
-          A woman admitted to his ward with a late miscarriage four days before, unreviewed since, now becoming very ill with sepsis. (She has now recovered well. This is one of the top five causes of maternal death. On the same day, we dealt with two other conditions from the killer list – obstructed labour and eclampsia. In each case, we did some things well, and some things slackly, on this occasion with good outcomes.)
-          A baby on its mother’s back outside the children’s ward, unrecognised as having been ill, with meningitis, having seizures.
-          The report of a 3 year old child admitted in the night after a fall, very unwell with perhaps a broken leg. Before being seen by the AMO on the morning round, the child died. (Perhaps from multiple injuries plus preceding chronic illness). This information was given in the hospital’s morning report, in the same voice as if the boy had grazed his knee. No-one but us was shocked.
Of course many other good things had happened. In the historical context, it was just a normal day. Ward staffing is often just one trained nurse, hoping to make some impact where she can, without aspiring to be all-seeing and all-curing.

Sion and I asked for a meeting with the Hospital Director (Isaac Mgego), and Deputy Director, (‘Katibu’), to explore how we can move more purposefully along the road to progress. We need not – we cannot – solve all the problems at a stroke. We are unable yet, for instance, to influence the advanced state of neglect in which many patients arrive, (for instance the child after the fall). We should, however, be able to promise that no-one will die casually in our hospital. We should be able to muster the plentiful but unfocussed good will, and to harness it into targeted proactivity. We need to recognise the seriously sick and the emergency situations, and deal with them as thoroughly and uniformly as our resources will allow. If we are to engage with communities, and to encourage early referral and attendance with serious problems, then we must be clear that here in the hospital, we deal with those problems assiduously. Many interventions cost prohibitive amounts of money, but carefulness is (almost) free. Can we make this next step?

Of the many determinants of progress in an institution, there is one which matters more than all the others combined: Does the boss want it? Isaac and Katibu don’t just want it, they are hungry for it – as are many of the staff, so it turns out. They are like seeds in good soil waiting impatiently for the rain, so that they might become green shoots. The rain is just a bit of water. All the goodness is in the seed, and these are good seeds.

Out of our meeting came the idea that we would set out a charter of expectations in dealing with emergencies and the seriously ill; of minimum standards in initial management; promptness; communication; and monitoring and review. Much of this fits neatly with the steps we have already taken to reduce delays in maternity crises. We have slipped a little in this, but not much. Without proactivity we will slip more, but I detect a subtle dissolution of antipathy to this self-imposed harshness. We see, (for instance today), a maternity ward where the last dozen emergencies, mostly late referrals who had already been to the TBA, have been dealt with promptly enough to produce twelve thriving babies twelve healthy mums. Next week we meet with the extended management team to take these ideas further.

That will follow several trips planned for early in the week, where explore further the dream: outreach into five communities; linking to the work being done by Hands4Africa; and in the fullness of time, having systems for early referral of critical cases. Thereafter, we will need an enhanced front line of Clinical Officers, and the first steps in making that a reality will also be taken next week, when we visit the nearest CO training school, near the capital Dodoma.

Dodoma, one hundred or so years ago, was a small German colonial trading town, sucking the profit from a vast, un-mapped and untamed country. Bantu and Nilotic tribes eked a subsistence in widely scattered villages, whilst the nomadic Masai jealously herded their cattle, and wreaked occasional terror on both colonists and missionaries alike. A bloody uprising of enforced labourers had just been put down. Stanley had found Dr Livingstone deeper in the country a couple of decades before, on the shores of Lake Tanganyika. Jump forwards fifty years, and there came independence, and Nyeyere’s dream of harmonised growth of a united people. The unity persists, despite extreme poverty, and Tanzania remains one of the few countries not to have experienced post-independence coups. One reason is the real determination to deal equably with the twenty-or so main tribes, most of whom still speak their tribal language at home. And so it was that Dodoma, being in the centre of the country, on a major cross-roads, was later chosen as the capital.

I will tell you more of it when I have seen it, but at the moment I continue to be struck by how much the inner areas of the country would still be so recognisable both to Dr Livingstone, and to the predators who now limit themselves to the many huge game reserves in the country. Which leads me seamlessly to our visit to one of them on Saturday – Mikumi national park.

We of course we were on the look-out for the Big Five: the five most terrifying animals on the planet. Sion saw three of them in the first few hundred yards: mosquitos, tse-tse flies, and me. Everything else would be a bonus. But what a bonus! We stopped at a water-hole, (which had a tse-tse fly trap, enabling us to get out of the car. What we had not taken into account was that in getting out, we might let tsetse flies in, fleeing from the trap. One of them showed its gratitude to me later with a kiss, and I anxiously awaited to see if the lip-marks would turn into the characteristic ‘eschar’, signifying impregnation with sleeping sickness. It didn’t, but I’ve ordered online a new pillow, just in case.)

The water hole was the size of a football field or so, and, it being the dry season, much of the local fauna were not far away. The most immediately attention-grabbing were the humping hippos, oblivious to the midday heat, taking time out of their busy being-a-hippo schedule to produce some more of the species. Besides ourselves and one other group voyeuring, were a monitor lizard; a variety of crocodiles; a flock of egrets; some Egyptian geese and their impressionable young; a batalla bald eagle (and a juvenile who was just thinning); two fish eagles; six ground hornbills; a herd of buffalo; an extended family of baboons; and five marabou storks.

You cannot begin to imagine marabou storks. They have the largest wingspan of any extant bird, and have been recorded as being up to nine feet tall. When they flew, they blotted out the sun for a while. It was extraordinary to witness that such carcasses could heave themselves so effortlessly up into the sky. It reminded me of my rugby career. The reason they did actually heave themselves was, quite unbelievably, that they were mobbed by saddle-billed storks – even taller, but ganglier birds – presumably their longer reach and defter footwork gave them an advantage, as long as they could avoid a clinch. On the way out, a herd of elephants seemed pretty ordinary in comparison.

As we climbed back along the hot and dusty roads to Berega, it was difficult to tell that we had left the game park, except that the tops of the trees were less nibbled. It struck me that for a rural Tanzanian grandfather, who was a young man when Dodoma became important, and a little boy of 3 years when the colonial powers were still the dominant force; the view from his hut would have changed very little. What might be a very welcome sign to him would be some green shoots.

Let’s hope that Dan does not make them into Pousses Vertes Rustiques a la Campagne.



Baboons, a fish eagle and marabou storks


The edge of Berega village


Ground hornbills and a stork


Hippos humping





 Baboons and storks

Wednesday 17 July 2013

04B Pics for this week

 Berega Hospital entrance at the end of the road
 The local river
 The road in Berega village
 Sion full of ten-a-day
Ten-a-day waiting to get me

Sunday 14 July 2013

04. Beginning by being here

04.  Beginning by being here
14th July 2013

I hesitate to tell you my dream for mothers and children in rural Tanzania. Aspiration – yes. Plans – even better. But dream? Dreams are vague. Dreams are frenetic. In dreams, you are at the theatre, supposed to be on stage in two minutes, but you haven’t written the play yet, when someone, initially your mum or possibly your sister but you gradually realise that it is your biology teacher, comes in to hurry you, but you discover that you have no clothes on, so a friend, who is later a different friend, takes you backstage, which opens onto city rooftops, so that you can fly with him, who is now them, pursued by your brother who has got your shoes, which when you put them on you realise are rugby boots, and your antagonistic nemesis from primary school passes you the ball, and it turns out that you can actually run faster than you can walk, if you didn’t need the loo so much, but as you approach the try line, your friendly workmate redirects you onto the stage, where the audience awaits your first words, increasingly disquietedly, until you are saved by the fire bell going off so relentlessly that you wake up. (Is it just me that has dreams like this?) (I’ve just re-read that paragraph, and even I can see that I need help.)

So a dream is perhaps not the best way ahead when thinking about sustainable development. It is too easy to leap haphazardly hither and thither, prompted by the exigencies and consequences of deep-rooted under-development in this worrying corner of the world. We are beginning, therefore, to collect together our thoughts into an aspiration; and to distil how we might take the first steps in turning that an aspiration into reality. Choosing those first steps, however, is not quite as easy as it seems.

When I was in Africa before, I made many mistakes. A characteristic one was to assume that just because something sounded like a good idea, that I was thereby empowered to ram it down the beaks of the chicks in my keeping. A few cuckoos in this way were nourished. A decade and a half later, I was teaching the management of change, on a two-year sabbatical. (On the basis of what qualification, you might reasonably ask? These were the Blair years, I would point out. I looked like I knew.) (And, more importantly, I knew how to be engaging by not wearing a tie.) So there I was, teaching others what should happen when you unleash a vision statement or Gantt chart or project manager. Dreams would become reality. System development. Admirable and well worked tools.

I had never grasped then, however, and probably still have not now, what actually makes human beings behave in the way that they do. If you are a husband, for example, married to a loving and beautiful spouse, why is mowing the lawn the second thing you think of when you wake up on a sunny summer Saturday morning? Is it the prurience of your garden maintenance management consultant? No. Much more likely, your plans and actions are manifestations of a devoted adherence to your woman’s unspoken desires. And if you are a wife, married to a loving and near-perfect husband, why is giving both verbal and written guidance for the conduct of your beloved’s day, both the first and second thing you think of before breakfast? Project management? Surely not. It is the joyful desire to give your man the opportunity of a day well spent. What really controls behaviour is not so much good ideas, as relationships. It all depends on relationships. I can only sustain positive change in that of which I am a part. So we begin by being here, together, where we are.
But in Africa, where we are is not always a good place.
               
When I began the maternity ward round on Tuesday morning, I was feeling buoyant. During the night, I had assisted Hizza at two caesareans, both done with ease and skill using his newly-honed techniques. In each case, the midwife had dealt well with the (anaesthetised) baby, taking account of previous nudgings and admonitions. The second caesarean, despite being at 5.30am, with an exhausted team, was ready to start within 35 minutes of the call. Very satisfying. And – the team were relieved at the lack of time-wasting! Massively satisfying. But when I later arrived on the ward to ask how the first lady was doing, I was told, ‘fine’. She pointed to the woman half way down the ward, un-nursed, lying on her back with an airway in, still deeply unconscious.
“Has she had any observations yet?”
“Yes.”
“And…?”
“Blood pressure nil”
“Blood pressure nil!!!?????”
“Yes.”
“And she’s fine?”
“Yes”.
Actually, she was fine. The nurse has just not been able to find the BP because the BP cuff was faulty. Guidelines for post-op care of course exist in Tanzania, but they might as well not, written as they are by someone else, somewhere else. Here, the culture in which we work has been “if you die, you die”. That is not neglect; it is the way. In the next bed was Joyna. In a previous night, Joyna had made the motorbike journey from Mtumbatu, just 20 bumpy minutes away, in labour in her sixth pregnancy. Two previous caesareans had led to two healthy children. We added another to each tally. Three home deliveries, however, had resulted in three stillbirths. Despite this, she had had no antenatal care. A quick survey of the ward showed that more than half of the women with previous pregnancies had had at least one baby die. Indeed, two women on the ward had lost their babies this time round – one to eclampsia, and one to congenital abnormalities. (Her fourth successive child to die at full term). Death is where we are. Whatever the first steps on our journey to a new reality, they will not be the pinning of guidelines on the wall, and the pointing of an angry finger at those who do what they always did. (That comes later?)

The first steps then. We have already begun, and my part is tiny, so don’t get the impression that I am Ghandi. What I bring is simply knowing that it does not have to be like this, and falteringly imparting this to the staff. The vehicle in which we will be travelling is their belief that it can be different. Slowly, we are gathering an impetus fuelled by getting it right. Emergencies dealt with promptly. Babies well nurtured. Surprising survival, achieved together. Where we hope to be, as soon as we can, is that in every common mother or baby emergency, we do a good job, (mainly), based on the knowledge that we can, and the understanding of how. With that solid beginning, we can think of progress. We plan to engage with the people; with the TBAs; with the ten births that happen out there for every one that happens in here; with the Village Health Workers and their utter lack of any resource; and with the communities that Hands4Africa will be financially developing, educating, mobilising, and empowering. On Monday we have a meeting where we will decide the next steps. More of this next week.

By the way, I forgot to mention last week that Barack Obama came to visit. Not actually to Berega, and not specifically to see me, (as it turned out), but nevertheless he chose Tanzania over his native Kenya to water his flock on his pastoral sojourn across the planet. In a completely unrelated item of news, Tanzania has found some new mineral resources in the south of the country. How strange for me to be just a few hundred kilometres away from the leader of the free lunch. Only joking. I meant free world of course.

You do get the wonderful feeling of a free world here. As I write, harmony singing is ringing across the valley from the gathering place on the hill. When there is no singing, the chattering of children and the clucking and clicking and cooing fill the spaces in the African sound. The evening fires at the entrances to homes welcome back the workers. Then the stars come out, and the Milky Way is painted in a rough white stripe overhead. It really exists. For the last five or six nights the moon has simply failed altogether to pitch up, but, to be fair to the moon, this has allowed us to see the Milky Way in all its glory. There is even such a thing as starlight. (The other night, I lay in bed in deep darkness. I passed my hand several times right in front of my face, two inches from my nose. I could see absolutely nothing, not even movement. I opened my eyes and it was not much better, but a hint of starlight told me what my hand was up to.)

What else can I tell you of my week? I have lost 6kg already, since landing in Dar Es Salaam bursting with Emirates’ Foil de Poule au Genu. If I carry on like this, within a month and a half I shall be back to my birth weight. It may be of course that I have a zoonosis, (that is an infestation with a family of nematodes or amoebae), but if they have a family and I am just an unemployed man of working age, we have to wonder who has more right to be in my body.

I tried to address the weight loss on Wednesday, when the complete lack of any sustenance whatever in our kitchen led me to take the day off, and make the two-hour trip to Morogoro. Morogoro market is a wonder. In the market you can get not just fruit and vegetables, but kettles and cooking pots and string and bags and contraptions and tools for removing leeches from goats’ fetlocks, and a thousand other things more, and then more again. Innumerable stalls and makeshift displays are rammed into an old colonial shell. Rusty, broken, part-lengths of corrugated iron are woven together into jagged irregular projections of roofing, nailed to crazy wooden frames, to protect the goods from the hot, sweaty sun. (I cannot be sure that the sun sweats, it being a star, but in Morogoro market, it seems to.) There is no fruit you cannot buy – except, bizarrely, apples. Heaps of pawpaw, mango, passionfruit, banana, tangerine, avocado, and untold others are laid out in little piles, each pile costing 500 Shillings – 20p. (But no Pink Ladies. No Coxes. Nothing makes you want more to be munching on Granny Smith, than her total absence.) Then the vegetables, the ginger, the garlic, the tamarind, the cumin, the spices I have never heard of, and endless sacks of things to soak for a week before boiling for a couple of hours then throwing away.

In several shiploads, I bought enough for ten-a-day for a decade, and then my reward: Protein! At the Morogoro Hotel, I ordered half a chicken, which I reasoned should be enough at least to put weight back on my shoulders, so that I would be able to undo the top button on my shirt without it slipping noiselessly to the ground. Sadly, I had forgotten about East African chickens. When they peck around your door all day, and from time to time perch immediately outside your window to practise crowing for much of the night, they look not-far-off normal-sized. It must be all feather. If you hide a Tanzanian chicken drumstick in a box of Bryant and May, you’ll never find it again. I duly gnawed the bones, marvelling that these creatures had the strength to walk, far less scrimmage.

And so back to Berega, privileged to be arriving by car, with food.
In every direction around, small red  mud dwellings, wisps of smoke and noises of evening marked the villages and communities that the hospital serves. Bands of smiling ragamuffins waved us past. Women with babies on their back and unlikely loads of firewood or well-water on their heads eyed us curiously. The dry river beds and straggling weedy patches of maize in our remoter and higher part of the land contrasted with the rich watered fields around Morogoro.
Might this be the very generation in which we make a different expectation for the people of remote African villages?
We have a dream.




 Laurence Wood
email.lozza@gmail.com

Saturday 6 July 2013

03. A Road Ahead Beckons

03. A Road Ahead Beckons
7th July 2013

Whenever I write the word ‘mentorship’, the spell-check offers me other options – ‘mentor’s hip’;  ‘mentor sheep’; etc. The reason is that Mentor was not, originally, a verb, but a person. (If you have ever been mistaken for a verb, you will know how it feels, having these accretions and conjugations added to your name.) Mentor was in fact a wise Greek, who gently looked after the interests of Odysseus’s son Telemachus, whilst the former was de-Trojaning.

A mentor now is a father figure; a whisperer of wisdom; a nudger of destiny. It was under that guise that I arrived here nearly three weeks ago, and gradually I begin to understand. In one way, my expectations have been realised. One of the ‘AMO’ Medical Officers – the delightful Hizza – has recently joined the on-call rota, having only previously performed six solo caesarean sections. The AMO is the longstop on call – the last player before an unwelcome boundary. My mentorship of his surgical skills has produced a satisfying immediacy of change. He has raw skill, and his self-ratified, sometimes makeshift techniques have not had the chance to become ingrained. He now knows how properly to control a bleeder, how to close a uterus so that it does not look like a Cornish pasty, and how to enter the abdomen through the bikini line, a full generation before the arrival of the garment.

As regards the two experienced AMOs, however, I think that I am learning more skills from them than they from me. If that were where it ended, then on return, short of finding myself on hand to reduce the dislocated hip of a Coventry cattle-herder, my trip might have been wasted. Mentorship, however, goes beyond the imparting of skill, and steps gingerly on the road to progress. What I am unintentionally bringing, perhaps more than anything else, is an expectation. An expectation that people might live, and live happily. I am bringing some understanding of how we in the UK expect a maternal death only once in every 10,000 deliveries, where here it is once in every 100, or 50, or even 30 in the remotest areas.

With regard to baby death, the figures would be even more stark, except that no-one knows them. Most dying babies never arrive at hospital. Some, unsalvageable, do – four this week, for instance. Had I stuck to my idea that mentoring was only boosting the skills of the hospital staff, then how would that have served baby Glory? She was born breech, at night, in the distant fire-lit mud-hut of a friendly but foundering Traditional Birth Attendant. A long motorcycle ride later, any hope of saving Glory had been dissipated with each degree of body temperature she lost. No-one cried. No-one does. Perhaps it is the inurement to tragedy that my mentorship might influence most. For the staff, inurement becomes habit, and habit becomes self-fulfilling prophecy:

“This lady needs a caesarean right away – she has an obstructed labour, and the baby is becoming distressed”. (Exit stressed obstetrician stage left, to jostle the theatre team. 30 mins pass. Enter same obstetrician looking highly inflammable. Mild groans proceed from a prone figure on a rubber sheet. Muffled chicken noises pass by a rear window.)
“Why is she still here?”
“We are waiting for the laboratory, and the security guard could not find the anaesthetist.”
“Please! Come on, let’s go!”
(Exeunt).
No-one is bad or callous. No-one is meaning to delay. Everyone aspires to an early resolution to the problem. Yet a weary pointlessness sometimes creeps into the bones of the players.

Enter mentorship, stage right. The AMOs have in fact long abhorred the difficulties involved in making things happen quickly when needed. So, prompted by a higher expectation, we talk. We listen. We probe. We explain. We discuss how we might do it differently. The chief AMO calls a meeting of the heads of department, along with me, the AMOs and the hospital superintendent. We explore the options. We resist the temptation to procrastinate. We decide, to my almost worried surprise, that we will set 30 minutes as the maximum time to have elapsed, from making the decision that we have a maternity emergency, to beginning the operation. We adopt a system of monitoring the cause of any lapses. We meet with all staff and agree. Three out of the next four caesareans meet the target.

My unexpected and unenviable job now is to embed and popularise not just this development, but the whole idea that situations can be improved. Not just that they can be improved, but that a mechanism can be devised for dissecting the issues when we don’t make it. In the UK we would call it Significant Event Analysis, and it has been evolving for four or five decades. Here, it has no name, and it is as young as that first baby saved.

Forward movement having begun, mentorship is soon going to find itself hard-placed to keep up. Another hospital meeting took place on Friday, again with the overarching hospital boss in attendance, and that was one in which hope for the future took tantalising shape. It began with the excellent Abdallah, the head AMO, presenting his field survey of maternal mortality, and attitudes to hospital birth in the villages we serve. Predictably, most women attend the TBA, and 90% of those that arrive at hospital do so with TBA herbs already prodding away at their innards. (19 out of 20 adult hospital admissions have, as their recorded occupation, ‘Peasant’.) Adballah’s dream is to reach out to the villages, and to build collaboration, mutual understanding and early referral. What makes it more than just hope, however, is the potential contribution of a man whose name is not currently a verb, but should be.

Brad Logan is an American OBGYN who came out just four years ago, to see what he might do to help. Finding the situation that I am now beginning to appreciate, he decided to dedicate his awesome can-do talents to making a difference to rural poverty. The charity Hands4Africa was established, and in the blink of an African eye, one fortunate village has work and money for the first time. Not content with that, he has bradded away, not daunted by circumstance, not accepting impossibility, until his extended goals are beginning to be realised.  Water, food, shelter, education, transport – and local health care – have now begun to be tackled in a sustainable way. It is just a beginning for this part of Africa, but an inspiring one. Now, he intends to brad five further communities – the very ones whose TBAs we want to reach – and suddenly the prospect of truly working catalytically with traditional communities looks less daunting. Much more of this, I hope, as the story unfolds.

Sion and I even had our gastro-intestinal systems bradded, when the Man of Iron pitched up on our front door step with baskets of actual food.  Plus extra-virgin olive oil! Spices! Brown bread! What a hero! Here in Berega, if you know where to look, it is true that you can find food of sorts, (unless, it seems, you are either a dog or a female chicken. The former, seemingly immune to the ubiquitous presence of the latter, are mainly dog-bone partly covered in fur. Pets are not a concept to have penetrated very deep into the Dark Continent. Hens are equally thin, despite the relentless scratching under every bush. Their reluctant ovaries periodically expel what is locally referred to as an egg, but is in fact one sixteenth of an omelette. Cockerels, on the other hand, seem unreasonably healthy, and shout Gallic jocularities to each other for the couple of hours leading up to the main jamboree at dawn.)

Anyway, food. Yes, you can get it in Berega, but, (not counting stuff that comes in sacks), it is all fruit. Bunch of bananas the size of a flock of toucans? 16p. A dozen oranges? 30p. The entire collection of tomatoes displayed on a makeshift counter on a village path? I didn’t have a banknote small enough. I had begun to experience the early pangs of ten-a-day poisoning, which presents in the same way as pizza deficiency. My nutrition, now bradded, is fully girded for the challenges ahead.

By the way, I left you with the wrong impression when I said that I was not living with a skillet-wielder. Sion, it turns out, can make an impressive Thai curry out of what I would have regarded as barely compost-able materials. It is only fair then, that in return I am passing on to him some surgical skills. On Tuesday, he did his first Caesarean. A large crowd had turned out in the theatre for this planned case, and it was in buoyant mood that we entered the room. Immediately, however, for me alarm bells began to ring: Simon the Zealot was there. Doubting Thomas was there. But where was Peter? Where were the sons of Zebedee? These had become reliable friends in just a short time here, and it was with trepidation that I realised we must undertake the procedure with just two of them.

The hospital has just twelve theatre gowns. They were recruited, one by one, by previous itinerant wise men. Far from being disposable, they have faithfully served generations of visiting surgeons. Some of them are just rough and rustic, some more sophisticated. All of them you take as you find. But when you need them, they are always there. Except today. It transpired that yesterday’s emergencies had used up all bar Simon and Thomas. (The Iscariot is kept for dirty cases). At the end of yesterday’s procedures they had all been washed, and were now hanging out on the Mount of Olives, behind the theatre block. So no scrub nurse, then, just me and Sion.

It went well. Sion has done a couple since, and the current score is Thai Curries 3 Caesareans 3. Sion is on call today, so a play-off is imminent.

Let me finish with a theatre gown-related theme. Caesarean section is the beginning of life for as many as a quarter of the population of the planet. When we do one here, we have no clean gowns, no modern sutures, makeshift masks made of bits of muslin, rudimentary anaesthesia, no modern equipment for the resuscitation of the baby, and, well, too many other paucities to count. We even, at the end of each procedure, wash out and recycle the bigger swabs. This parsimony allows us to keep the cost to the woman of a caesarean at £24 – the monthly salary of a nurse, and an inaccessible fortune to a rural Tanzanian. Thus the need for much bradding. In the new cooperation we hope to foment, we will need to perhaps halve what a woman pays, in order to have fighting chance of encouraging early attendance when problems occur. This needs money. So thanks to Thea, and Ann, and John, and Worcestrians in general, for money already generated, and for the forthcoming sponsored climb of Kilimanjaro. Your death by altitude sickness will not be in vain.

I’ve overshot my word count this week, but as it was self-imposed, I don’t care. I wanted to tell you that many positive things are afoot. With people like Brad around, maybe this will be the last generation of Tanzanians to endure nature at its harshest.

It remains to be seen, however, whether by the end of my two months, anyone other than Hizza and Sion will have been Laurenced.

Laurence Wood
Email:    email.lozza@gmail.com