11. Us versus Mother Nature

11.  Us versus Mother Nature
22nd September 2013

In the six weeks since I left Berega, two mothers have died in the hospital. One young woman was unfortunate enough to develop eclampsia at 28 weeks of pregnancy. Pre-eclampsia, (the stage before eclampsia), is a malignant type of high blood pressure, which eventually picks off the organs one by one. Once the brain begins to be targeted, convulsions set in, and the disease is now called eclampsia. Treatment to hold back the fits and blood pressure can provide a window of enough hours to deliver the baby, and then to get on with bringing back the mother. 

The worst eclampsia cases often occur at a premature gestation, and in the UK, the obstetrician must weigh the whole situation in deciding the timing of delivery: here in the UK, delivering a baby at 28 weeks results in a 90% chance of it surviving. In Berega, the figure is zero. No-one will have time and emotional energy, however, to grieve the baby: the mum's life is the priority. Her brain, liver, kidneys, lungs, heart and blood have to be coaxed back to normality, in a part of the world where the nearest they get to Intensive Care is a blood pressure cuff that works, used by someone who knows what to do with the results. Even the IV fluids are home-spun and the 'giving sets' erratic. In rural Tanzania, many do not make it, and nor did this terrified woman or her baby.

Saving a woman's life once eclampsia has set in is like trying to prevent death from lion attack - it is only hard if you did not see it coming from a long way off. Eclampsia is usually preceded by weeks of symptom-free high blood pressure. This woman would have been fetching her water and cooking her ugali without ever being aware of the silent predator that stalked her, nor of the tragically few days she had left to live. 

I paint the picture in all its poignancy, to highlight the harsh injustice of Nature in the raw. The reason that Chagongwe and Mnafu and Maguha and Tunguli have two-hundred times worse maternal mortality than Estonia is not because the latter has an ITU in every village. They do, however,  have proper drips, and blood pressure cuffs, and people who know what to do with them. And roads. And systems of transport thereon. Preventing death from eclampsia is as simple as a village health worker (VHW) doing regular blood pressure checks, and referring in anyone whose BP is above a certain level. When I look back on my choice of career, this was a central influence: turning potential tragedy into joy by such easy means.

The other death was also deeply harrowing, and I will not give details. Suffice it to say that the problem was the combination of obstructed labour and haemorrhage, which conjunction is a grim reaper of young women in rural Africa. Again, in the final stages, the solutions are often beyond the resources of a hospital like Berega, but earlier on much can be done. Seeing the woman before the labour became obstructed would be a big advantage, and once more a VHW has a role in encouraging waiting at the 'waiting mothers house' in the hospital, when labour is approaching. This would especially apply to those for whom a troublesome labour might be anticipated - for instance a slim sixteen-year-old in her first pregnancy. Better still is for her not to get pregnant - but where does an uneducated village girl even  get the knowledge about contraception, far less the methods. Once more, VHWs can provide simple solutions.

It was a great joy, then, to help steer Berega's community development plan for mothers and children to its next stages. (see the updated blog post.) This began with triple and quadruple checking with the hierarchy at the hospital, and their advisors, that we have indeed captured their own vision, and that this is not something being done to them. Their response has been an overwhelming and heartfelt supplication that we might continue to make progress together towards the vision that they themselves set, (by candlelight in evening meetings in the mission house, was it just two months ago?) The repetitive listening process is a powerful instrument for change: sometimes it is only on the fourth reading of what will become our catechism, that we spot the flaws and subtext and difficulties. The major changes made so far reflect the importance not just of delivering babies safely, but of trying to prevent them becoming one of the one thousand under-fives that die in Berega's territory annually. 

Success will depend on bringing together as many as have a part to play. Three of the key agencies at the UK end are the Diocese of Worcester, the charity BREAD. and the charity Mission Morogoro. The latter two have as their entire raison d'etre the development of Berega, although coming at it from different angles, different parts of the country, and different funding sources. (Worcester Diocese has a wider brief of course, with the cure of the souls of half a million Worcestrians never something to be underestimated.) At the meeting we shared our different takes on how we might help in the future - and there are as many different takes as there are different needs. Achieving focus, unity of purpose, and division of labour is worth all the effort we will put into it. When obstacles inevitably arise, what controls our ability to remove them is not so much our power, as our combined determination.

Meanwhile, the Charter of Standards at Berega Hospital is being translated into Swahili, with the intention of giving a copy to each and every member of staff. Given that this strategy has come from the hospital management with no external influence other than initial catalysis, I am heartened to know that they really mean business.

Hands4Africa is another major player, and Brad has been honing down his thoughts and sharpening up his tools. We hope that H4A will be a major influence in working towards transport solutions. In this week alone at Berega there have been three major road traffic incidents, the biggest being twenty-five admissions in various states of broken-ness. They all survived. When the rains come, it gets worse.

Of course it is not only in rural Africa that such accidents occur, and blog readers will be devastated to know that I myself was unceremoniously unshipped from my bicycle on my first outing since my return. Coming down a hill towards a gate across the cycle path, my version is that I swerved to avoid a mother of quads, and, in a feat of acrobatic heroism, flung myself and the bike into a paratrooper shoulder-roll when the most vulnerable of the quads went back to pick up her dolly. My fellow cyclists' version is that I was going too fast, and sailed over the handbars like a flying frankfurter. Mother Earth eventually broke my fall by smashing my helmet into my head, in the process taking two inches off the length of my neck. Whichever version you care to believe, Mother Nature comes out of it as being hard and uncompromising. She needs us to take her in hand.

10. The Emaciated Mzungu Memorial Trench

10. The Emaciated Mzungu Memorial Trench
8th September 2013

Today it is raining, for the first time since my return. (Was that really three weeks ago?)

“That’s not rain”, a Tanzanian Crocodile Dundee would say, “This is rain!”, unleashing from behind his back a vast torrent, whence river and road became indistinguishable. Twice a year in Tanzania, the oceans and lakes and jet stream and sun get together, and for a few months fill the skies with surprised rivers, who had expected to be more terrestrial. They very quickly establish their fluvial rights, however, and pour down to earth, rushing in every direction in search of their familiar banks.

In the process, they make something of a mess of the roads. Months of sun will have hard-baked the dirt roads, but also fractured them. Then stones below the surface get dislodged by over-burdened traffic, and the fissures get wider. The more traffic on the road, the more the need for its integrity, but, ironically, the more the crunching and the cracking. Thereafter comes the rain, and the grateful river of water surges down the rifts, dislodges future silt, and leaves behind swirling furrows crossing the roads this way and that. During the rain, the dirt roads are all-but impassable, but when the sun comes out, it serves to dry the furrows into ruts and bumps that challenge even Land Rover suspension. And there aren’t many Land Rovers.

The front drive leading to our mission house was a case in point. The house, (as you will by now have seen on You-Tube), is tolerably comfortable, and the sitting room looks out over the steep valley to the hills beyond. Many times I have sat on the verandah, gazing emptily towards the dry river bed far below, wondering what to say in the next blog, but distracted by tantalising thoughts of distant sausages. It’s a beautiful valley, but as a result of its steepness, the rain leaves the front drive less a road and more an assault course. Being circular, the rain cannot simply run down it, and so reluctantly hacks it into furrows, as it charges down the hill towards a tumultuous reunion on the valley floor.

Water, however, despite its destructive capacities, is very biddable. It only turns your front drive into a ploughed field because it is trying to get out of the way, and if you give it the option of getting out of the way more easily, it readily accepts. Thus the Emaciated Mzungu Memorial Trench.

The story went like this: More than a month in to my stay in Berega, I was a wizened, puny vestige of my former self, with no opportunity to exercise, (other than lifting an occasional heavy pan of inedible yellow things, in order to discard them on the compost heap). On our visit to Dodoma, however, I saw a pick-mattock for sale, and pounced on it. A mattock is a beast of an instrument: Where a hobbit would use a hoe, a cave troll would use a mattock. It goes without saying, of course, that a pick-mattock is better for trench-building than a grubbing-mattock, because the pick-end enables removal of bigger rocks, whilst the mattock-end can hack out a trench, oblivious of roots and rubble. The entire tool, with handle, weighs about twelve kilogrammes. Having, with the pick, wheedled any stones out from the path of the mattock head, you then unleash the mattock onto mother earth, gashing a deep furrow in her flesh.

At the top of the drive, I planned the route that the water will take when the first rains arrive in November. Passers-by on the road stopped to admire the efforts of the emaciated mzungu, manfully standing up to the might of Nature, and pummelling the would-be trench into existence. Being out of condition, I had to rest after each blow. I would have rested half way through each, had it been an option. By the end of two hours, a few inches of trench were already demonstrating their proclivity, by directing a litre or so of mzungu sweat down the hill. From the boys of the village, flocking incredulously around, a polite murmur of what I took to be awed appreciation sniggered between them and the gathering mosquitos.

The path of the trench I sketched out by two parallel lines running down the side of the drive, and onto the thirsty lawn below. The first half-metre, mattocked to perfection, is a veritable Suez. Sadly, however, I did not get much further with the trench before I left Berega, and Sion has now taken over. As a result of his blow by blow assault on the un-mattocked section, an Emaciated Mzungu Memorial Trench is now being grooved into the erstwhile random surface of Africa.

It will be completed. We know what we want, we know where we want it, and we have begun. When the rain begins to fall, it may be that we will need to take account of the way water naturally flows, but thereafter it will flow with a sense of purpose, reinforcing the trench more deeply with each downpour. As the perceptive will have noticed, I have just managed to ooze my way into a relevant metaphor: Although I am now back with my own tribe, the journey to safe childbirth for future mothers in Berega’s territory has begun. Careful hands are now deepening the commitment and purpose and direction. Things may unfold differently to our plan, but perhaps not by much. There is no going back to the random inefficiency of the past. It will be completed.

Beautiful examples of the irreversibility are the inspiring activities of Kofia in Guildford and environs. Their thriving website is the hub of both fundraising and spreading of awareness, but I particularly love the fact that they have knitted nearly 500 hats for Berega babies – and arranged a means of getting them there. Part of the vision is that once babies have been delivered safely, (which involves staying warm), they will continue to thrive when they go back to the villages. We want to follow up women back in the remote parts, and help ensure that their babies grow into healthy children. Having a Kofia hat might become the hallmark of a new era of health for this new generation of babies.

Meanwhile Brad, from Hands4Africa, is enthusiastic and inspired by the idea of a combined assault of community development and a community-based maternal/child health programme in Mnafu. It will allow women with no current realistic access to health care to have their babies in safe settings, and to raise their children without the expectation that 10% will die. The plan will now be fleshed out, having now decided that in the first instance, the priorities are bespoke transport, and a health facility at Mnafu. Economic growth and education will follow, in partnership with the development of systems for safe childbirth and healthy under-fives.

The Diocese of Worcester has completed a hugely successful sponsored climb of Kilimanjaro, raising thousands of pounds. A dozen or so people, some of whom had suffered altitude sickness whilst training on the Malverns, nevertheless managed to conquer the mountain. It was salutary to note, when flying home, that the mountain top was nearer to the plane than it was to the plains. I would have paid thousands not to climb it, so utter congrats to those who even tried. Meanwhile, I have been humbled and touched by the support of friends and blog-readers; and of others whose catalysis I will talk more of next time – thank you. We are poised to make a difference where it will really count.

Meanwhile, back in Berega, progress continues. Isaac Mgego, the hospital Director, is mustering forces at that end, ready and eager to begin a new era. Last month we saw reliable electricity become ensconced at the hospital. This month, for the first time in its history, a blood bank opened. It sounds a small thing, but until now, if a woman were bleeding inexorably after delivery, we would first have had to call in a relative or a compatible donor before we could give her blood. Truly life-saving.

By the way, talking of life-saving, those following the tortuous tale of my nutritional nadirs will be delighted to know that my life is no longer in danger. I have eaten more Pork & Leeks and Spicy Cumberlands than any man’s gall bladder should decently have had to deal with. My blood pressure and waist size are creeping up nicely, and the sentinels of my liver have sent out for reinforcements. Furthermore, my exercise tolerance is beginning to build, and my legs no longer look like articulated wooden spoons. Part of the de-wooden-spooning programme is country walking, and so it was that on Tuesday we went to the Peaks, and I once again immersed myself in English countryside. In the evening, pleasantly aching from ten miles of Derbyshire tracks and trails, fields and villages, woods and rivers, steep slopes up, steep slopes down, and even some steep flat places, all leading to deep satisfaction of arriving back where we had started from, I sat in the garden of the Devonshire Arms, and got outside a home-made game pie and a pint of ale, watching a yellow wagtail hop around the stones of a fresh, lively English stream. I was very satisfied to be home.

The next day, the full English breakfast strengthened me for the shock of the bill. A night in an English inn costs more than a month’s living costs in Berega. In fact I do seem to have overdone my response to the rediscovered capacity to spend money, which I was anyway always quite good at. In Tanzanian terms, my income is like the spring rain flooding down across my life, washing this way and that in lavish exuberance. I suspect that Mis (my wife) thinks I need mattocking.