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