An Englishman, Childbirth and Rural Tanzania: 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.