02. Settling in

2. Settling in
29th June 2013

Eventually, Jim proved less of a problem than I had anticipated. Jim is the name of the bat who, embarrassingly for him, misinterpreted our absence of electricity at night as an invitation to the party. (To be honest, I cannot be certain that his name was Jim. To find out the first name of a bat is never easy, and in Jim’s case I suspect that he was deaf as well as blind.) He must have been more bewildered than annoyed to find just Sion and I; and in place of a winged arthrodpoda-fest, only beans and peanut butter. We made our apologies and slipped off to bed. A rattle of the bat flap, a moonlight flit, and Jim went out of our lives as quickly as he had come in.

In fact, given the number of Englishmen who have variously been mobbed, eaten, gored, mauled, chased, chewed on or sipped at by African fauna, I have had far less trouble than you might have imagined, for someone living six degrees below the equator. For instance, in the eaves of the house lives a hornet, (perhaps more than one – they are so difficult to tell apart), with a body the size of a sailor’s forearm: but dive-bombing my coke bottle is, to her, just friendly aerobatics. The monkeys that sometimes clamber playfully on the rooftop at sunset were mortified to hear me talk of an alarming screech. By day, butterflies flutter at half-speed. Scrawny chickens cluck, scrape, crow and peck at nothing in particular. Torpid dogs in the shade of a hard-baked house, raise a welcoming eyebrow. I haven’t yet seen a mosquito, (though two have seen me, and checked me out). African animals in mellow mode. As I walked to hospital the other evening along the dusty, broken, bumpy road of packed red clay, some Masai drove towards me a small herd of deceptively wild-looking cattle. They gently brushed by me as if I were a scratching post. One of them winked the wink he uses for a favoured heifer, but then snortingly suppressed a bovine chuckle. Good job, because short of David Duckham-ing into a dry mud ditch, or manfully grasping his worrying horns and wrestling him to the ground to demonstrate my complete un-heifer-ness, I had little option but to stand there and make rasping noises, as of bull on wood.

It is no little relief to know, then, that at whatever time of day or night they call me from the hospital, I need not add fear of the animal unknown to fear of what awaits at the end of the six-minute stroll. What awaited me on Monday night was more shocking than anything I have seen, even in four years in Africa, three eventful decades ago.

Shoulder dystocia means that the baby’s head delivers, but then the shoulders are too broad to follow. It is one the most feared of childbirth complications by those who have the tee-shirt, because Nature gives you just ten minutes from start to finish to see if you were paying attention on your Obstetric Emergencies course. The art of delivery, says the course, is to rotate the baby to be face-down, by numerous means, at the same time as maximising the space by all-but impossible flexion of the mother’s knees and hips. Typically, shoulder dystocia happens in the UK when the baby is too big. Here, it happens more because the mother is too small. A lifetime of poverty and porridge leave far too many women much tinier than their genes would have liked. For such women, a better result is to have an obstructed labour, as long as it happens where a Caesarean section can start them on the road to safer childbirth. Better that, than test the African response time to shoulder dystocia, and the Clinical Officer’s memory of a distant and disembodied course.

NB – the paragraph is seriously disturbing – you may want to skip it. But it is real life, and needs telling.

What the course does not tell you, however, is how to deal with shoulder dystocia when it began three days ago. When the six-stone woman, having had two Caesareans, was persuaded by relatives to stay in the village, to be delivered by the traditional birth attendant. It does not say how to persuade the same relatives the next day that if the rest of the body of the long-dead baby has not yet been born, then help is needed. In particular, the course does not tell you how to console the inconsolable; how to de-terrify the terrifying; nor how to sit as the middle passenger on a motor-bike for a three-hour ride on fissured rocky roads, whilst between your legs is the head of your third baby, who died so long ago it that it seems like someone else’s existence.

We had to sedate the mother to deliver the baby, and if there is a daily individual prayer allowance in heaven, then I used two weeks’ worth in the next five minutes. Eventually, I managed to reach the posterior arm, and to slide it past the impacted body. Thereafter, the torque forces did their work, and the limp, lifeless body tumbled out. An iodine-and-saline cleanse of the infected uterus, plus intravenous antibiotics, and the mum will this time survive. Dr. Makanza, one of the excellent AMOs, was present and pushing supra-pubically, and I reflected on the irony of having a real-life demonstration as to how to manage this desperate condition.

Not that I have much to teach the AMOs, as it turns out, despite my putative purpose in being here to be a specialist mentor precisely to this grade of practitioner. In Tanzania, more than 80% of the population live in the rural parts of this vast, majestic and inaccessible land, but more than 80% of the doctors are in the cities. There are only 100 or so obstetricians in the entire country, for a population nearly the size of England’s. Complicated childbirth in the rural parts is thus served by Clinical Officers, who have completed in three-year course in how to deal with anything that arrives. After three more years working as a CO, it is possible to progress to AMO, by means of a further two years of full-time training. (The cost of the course for two years, including food and accommodation, is £2,000. Cheap? COs don’t earn that in a year.) Two of our AMOs, (Makanza and Abdallah), have done more caesareans in their lives than most UK consultants, and certainly more emergency hysterectomies. What can I teach such people? Very sensibly, I have lowered my sights, (or perhaps raised them), to ensuring that our student COs have picked clean my brain on how to deal with the crises in maternity that they are so certain to encounter.

And so it was in sombre mood that I picked my way back home that night, glad that the moon had finished the shady business that seems increasingly to occupy its time at nightfall. When the moon turns up late, whatever its excuses, the resulting utter blackness has something of a primeval creepiness to it. I say utter blackness, but of course my torch makes it less utter, powered as it is by good old duracells. Reliable batteries here are as welcome as a simile. (You’ll notice that I am still struggling a little with the second half of my comparisons. I think I might switch to metaphors.) (A metaphor, by the way, is like a simile, only browner.) I am not sure how long the batteries will last, though. We rely on the torches to light everything after 6pm: our nocturnal bean-fest; our conversations; our annoying strumming of the guitar whilst the other person is trying to compose a text to his mum pretending that he doesn’t want to break the guitar over your insensitive head, whilst you try to find that elusive Paul Simon chord that doesn’t actually exist on the guitar; our teeth cleaning; our sluicing the torso with a cup or two of boiled river water; our ritual turning of the underpants inside out every week; and our Kindle-ing ourselves to sleep at an absurdly premature hour. (The mission house does have solar panels, the most welcome gift of a past occupant, but with an archetypal African-ness, the power only seems to be available from the ageing batteries whilst the sun is actually shining. There is an electricity pylon 20 yards from the house, but as yet there is no way to find the monumental sum of £520 to connect up the house; much less the even larger sum needed to properly electrify the hospital. Sion had long since inured himself to a year of duracel-powered evenings.)

Sion by the way. (The Welsh version of the Irish ‘Sean’.) What can I say? What a wonderful 27 year old human being. For a month he has lived alone, immersed in a culture shock as profound as it is up-ending. And yet he remains humble, positive and determined to make a difference. An aside to you, Sion: sometimes the seeming senseless futility of situations might blind you to the immeasurably powerful effect of your loving kindness, extended freely. Simply being here, trying, caring, and falteringly but surely progressing in Swahili, you are making more of a difference than any tangible result could ever quantify.

I seem to have reached my word limit and have hardly told you about the week. Of the sun and mountains; of the Monday market with its goods and chattels spread hopefully along the paths of the village; of the baby who died in my arms in theatre simply due to depressing delays; of visiting the hospital driver’s three hectare farm, as yet devoid of any intended flora or fauna, which he is slowly buying for £48; of incredulity at seeing the airstrip which every six months is flattened for the arrival of the flying doctor; of having been allocated the luxury of my very own theatre mask and hat, disposable in every sense, except that they must last me my two months; of the drug calculations being based on counting the gentamicin vials in granny’s bag; of scouring the hospital to find something with which to rupture membranes; of stoicism observed in too much detail; and of inexplicable hospitality and friendliness in the absence of much of what I had for granted.

And as for my purpose: well it seems that I have to unlearn some things before I can find my true focus. This next week will help. See you Saturday! Meanwhile, Happy Anniversary to my lovely wife!!!

01. The beginning.

01. An Englishman, Childbirth, and Rural Tanzania: The beginning.
22nd June 2013

Yesterday, I saved three lives in rural Tanzania. The previous Friday, I planted out my hollyhock and lupin seedlings in the front garden, before going for three pints in The Oak. In a couple of months, I will be back in The Oak, relishing those pints, those friends, that familiar life, and feeling, for a while, the inappropriateness of my twenty-first century English values and preferences.

Or perhaps not? Perhaps I will be changed? If I have the skills to make a difference to the desperate natural mortality in this beautiful country, will I want to stay? Don’t worry, my lovely wife and family, I will return on time; thinner, browner, wiser, and more full of peanuts than any Englishman since Albert Schweitzer, (who was neither English nor full of peanuts, but when you start a simile, you have to finish it, and I hope you inferred that the culinary choices in rural Tanzania, in a house with two men unused to wielding a skillet, are limited in the extreme, and are largely influenced by knowing which foods can be bought locally that contain neither goat gristle nor Salmonella.)

My journey began a week ago on the comfortable evening flight from Birmingham to Dar Es Salaam via Dubai. Well, actually, my journey began thirty years ago when I did my first Caesarean section in Africa. I had been a surgeon, peremptorily removing at will unwanted parts of people, and casting them disdainfully, (the parts, not the people), into a nearby bucket. It took me a few years to realise it, but from the moment that my hand miraculously pulled a living, crying, beautiful, wriggling baby from someone’s tummy, I was an obstetrician. Thirty years on, I am retired from my job as lead obstetrician in Coventry, and am back in Africa, to see if I can make a difference in just a short two-month visit.

And a difference is sorely needed. Around half a million women each year give birth in Tanzania, and every two hours, one of them dies. In England, it would be one death every week. Of the survivors, far too many are left with the crippling disability of fistula, (urine constantly emptying through the vagina because of a hole in the bladder); and so many lose their baby that it is hardly even a matter for consolation. The causes are deeply rooted, and I cower at the prospect of trying to influence any. I will not, for instance, be able to stop the rain in summer. If lakes have not yet realised that the hot sun is just tricking them into becoming clouds, then I doubt that I can persuade them otherwise. No wonder the water is angry when it fills the river beds, turns the roads to mud, and prevents the passage of anything but hippo triathletes. Neither can I change the beliefs of women in distant dusty villages, nor the practices of the traditional birth attendants, whose tea explodes your surprised uterus into action before you even have a chance to ask for a water birth whilst your partner, chanting whale song, cuts the cord with a pair of organic scissors dipped in tea tree oil. On Thursday, a woman came in from a remote place, with a dead baby and a ruptured uterus. Her other three labours had been normal, but the birth attendant underestimated the power of this practised womb. In the rainy season, the woman would have been another two-hour statistic, and I would have felt the futility of my good intentions.

But they are not futile, as the three lives testify! At 5.30 yesterday morning, in inky blackness, the security guard rattled the mosquito screens on the windows of our old colonial bungalow. He explained in Swahili the need for me to come, and I followed, (in English). A sad, dimly-lit room in one corner of the hospital quadrangle is the labour ward. A tiny 18 year old had arrived, and had been in labour for far too long. The baby’s head was stuck in the wrong position, wedged deep, deep, deep in the vagina. Someone, surprisingly, had listened to the fetal heart rate, (what difference would it make?), and it was wearily slow. Last week, a Caesarean section would have been ordered. The theatre night-staff would have been called from their homes in the village. The generator would have been powered up, and the feeble yellow lights would have reluctantly awoken. Habel, an excellent technician trained in anaesthesia, would have checked the drawers to see whether any spinal anaesthesia was available, and discovering none, would have poured the halothane into the gas machine. The frightened girl would have been lying on a rubber sheet in the corridor, without the luxury of anyone to comfort her. Eventually, the Assistant Medical Officer’s expert hand, reaching far down into her pelvis, would have discovered the degree to which the baby’s head was wedged into the friable and swollen tissues. Whatever it took to get the dead baby out would have been done, during which the mother’s weak condition would have been furthered compromised by blood loss and the inevitable entry of bacteria. A few days later after failing to stop the post-partum haemorrhage, she perhaps would have left these worries behind her.

But that is not what happened. Five minutes after I arrived, I was holding a desperately hypoxic baby in my arms, thanks to the wonders of the hand-held kiwi vacuum delivery tool. (Thanks Nicholas and Pelican Healthcare! This baby lived because of your hard work and kindness in getting the kiwis to me! Will Africa be able to afford these wonderful bits of kit?) The baby was quickly wrapped in a kanga – a thin, brightly coloured all-purpose piece of material. (Well, all-purpose except for keeping a baby warm, as it turns out.) When I called desperately for a dry one, the relatives unwrapped two more from the waists of passers-by. No neonatal crash team, no oxygen, no heating lamp, no suction; but half an hour of rubbing and pumping and squeezing and blowing and drying and warming, and a pink baby joined his confused mum, none of us really understanding what had just happened. Both are fine.

I skipped morning prayers, and, eschewing the temptation of a quick peanut butter fix, slipped back home to celebrate with a special breakfast of fried cheese sandwich and a cup of tea. The tea was surprisingly good, despite being made of powdered tea, powdered milk, and powdered rain-water.

I spent the morning lecturing the student nurses, having picked my way through the chickens scrimmaging around the languid nurses’ home. It was the epicentre of culture clash. Imagine when you were at school, and instead of Miss Bunsen-Burner, the science teacher, in walks a Pacific Island chief, in full feathered head-dress, who proceeds to teach you the history of Tahiti by beating the shrunken head of a former pupil on a goat’s bladder stretched over a hollowed-out coconut. Well, perhaps it wasn’t as bad as that, but we have so much to learn to undo our cultural elitism, before we step into an African classroom. More of teaching next time.

In the afternoon, a Caesarean, but I was just the assistant, so could not claim to have saved anything, except my need for sleep. The third life saved came later, and was more mundane. Another Caesarean, after nightfall. Another distressed baby. Another long wait. A general anaesthetic. This time, I am the surgeon, so as to show the afternoon’s surgeon any differences in our technique. The baby came out easily, but was blue and seemingly lifeless, from a combination of oxygen starvation during labour, and general anaesthesia arriving via the mother. Leaving Dr. Abdallah to sew up, I spent, for the second time that day, half an hour of vigor, pushing a baby up the steep slope towards survival. Today I had the joy of seeing him getting to know the outside of his mum. (“She smells like mama, but she’s got a face like a placenta”).

There is too much else to tell you this week – bats and termites; the wonderful Sion; showering with a cup; such friendly people; cleaning teeth with a torch in your mouth; Swahili faux pas; 100 things to do with a bean; and more. And, of course, more on the answer to the question at the centre: Can I help produce a sustainable difference? See you next Saturday.