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.