07. Yellow chuck-chucks

07.  Yellow chuck-chucks
4th August 2013

Yesterday, Mama Liz told me off for throwing a few old bottles and empty tin cans into the rubbish pit. Of course rural Africa has no mechanisms for dealing with waste, so, until now, in a system akin to A&E triage, we have had a three-way disposal plan for garbage:

-          Combustible materials that don’t produce a pall of rancid smoke choking the life out of Mother Earth, we burn mercilessly.

-          Plant waste - the 2kg of tomatoes you never got round to using; peelings of wizened sweet potato, (peeled with a knife, to leave behind Lowry-sized remnants for cooking); the inedible parts of the bruised papaya you bought cheaply last week; the edible parts of the bruised papaya you bought cheaply last week;  mango stones and peel, plus all the bits of flesh that aren’t inextricably woven into your incisors; the outsides of guacamole; yellow things that you never knew what they were and didn’t dare eat – these, and the like, we put on the compost heap, in the ridiculously optimistic expectation that in two years, compost will magically appear from what was not eaten by the monkeys, ants, termites, chickens, rodents, fruit flies, and what I take to be anti-compost beetles. (Indeed, an enterprising bushbaby has actually set up a small market stall next to the pathetically penetrable walls of the would-be compost mountain.)

-          Non-degradable waste – old washing-up liquid bottles, (the contents of which, in this country by the way, only leave your hands as soft as your face if you have previously dipped your face in bitumen then dried it with a heat-lamp); glass; tin cans; etc – we have been in the habit of throwing into the pit, where they await the inevitable.

Not so inevitable, Mama Liz says. In Africa, things have many uses, and, (if not living), many lives. In the UK, everyone’s cupboard-under-the-sink is full of the bottoms of Tupperware containers and the tops of different-sized ones. In rural Tanzania, however, there are no Pound Shops, and no plethora of containers. If you want somewhere to store your old bits of soap, what better than a recycled tin can? A glass peanut butter jar is a candle stand. Beer bottle tops become an abacus. If you make sunflower seed oil (out of, as it turns out, sunflowers), then old water bottles are perfect for storage. Even the washing-up liquid bottle has an unlikely future, as a squeezy container for zapping termites as they try to gnaw into the tired door frame of the family home. Waste not, want not. OK, then, this is Tanzania – perhaps just waste not. Africa re-sets your thermostat.

It is not only detritus which has multiple potential uses, but also everyday possessions. Chickens, for instance. They can turn pecked-at used-corn-cob into egg; they can warn you of danger; they can remind you that it is dawn; they can remind you that it is only one hour until dawn; they can remind you it is only two hours until dawn; they can turn chicken soup into actual chicken soup; they can add a clucking, chooking, scratching back-beat to the rhythm of rustic African life; and they can be used as currency by the poor, to pay, for instance, for a traditional birth attendant. Today’s chicks are tomorrow’s birth-price.

This came home to me powerfully on Tuesday’s visit to Nhembo. (Pronounced ‘Nhembo’). The previous night we had had a rainstorm of sorts, and so the road was damp and slippy. (Old folks here say that in the days when all between these mountains was low forest, we would often have rain in winter. As the trees left, so did the rain.) We took the back road out of Berega, into the big beyond. Small mud villages slipped by, with antiquity only momentarily challenged by our passing. After five or six kilometres, we found a side-turning, and tossed and tumbled down the slope to a river crossing. Women were washing clothes, somehow not swapping new dirt for old. The dry-season rain had left just six inches of water, but the semi-vertical banks challenged even our trusty ancient Land Rover. Abdallah, driving, told me that recently he had got stuck in this river, and the nurses had got out and pushed. They had thereafter conducted the clinic with one eye on the sky, but eventually arrived home safely.

Arriving home safely, however, is surely not a reliable turn of events on the other side of this river. We drove for an hour in all, and eventually pulled in by a dilapidated bare building, which turned out to be the local church for half a dozen villages around. The tin roof rattled gently on the red clay-brick walls. Inside, a couple of dozen home-made benches were not much more than rough planks on stubby legs. The only other furniture, a rickety kitchen-table altar, had been commandeered as the nurses’ station. The glass-free windows, all of different shapes and heights, looked out on straggly patches of crops assailed by the inevitable bush, with the mountains distant yet impressive. A tiny shed stood off at a respectful distance in a field, ready to be of service in longer sermons.

Outside, I had expected a trickle of women and children to arrive for their antenatal checks, immunisations, and growth-charting. In fact, more than a hundred women, plus their (mainly thriving) offspring stood around, chatting, laughing, milling. A few women sat under the acacia tree selling bananas and mandazi dough balls. I bought a bunch of small bananas with a 20p (TSH500) note, and the woman later dashed after me with the 16p change.

It was an awesome tribute to some unknown community health warrior that immunisation and growth-charting was clearly so deep-rooted. But what of childbirth? Where did they deliver? Who did the deliveries? How did they get to hospital if it rained? Abdallah began talking to some of the mums: Six children. All delivered here by the TBA. And you mama? Four children. Delivered in that small village over there. And you mama? Three children, all quick deliveries. The Traditional Birth Attendant barely had time to arrive and claim her chickens.

But what if there are problems? Then we come to Berega. How much does it cost? TSH 5,000 on a piki piki (motorbike) is the normal price, but when you are in trouble in labour, and need to go with your sister mounted behind you, the price is TSH 20,000. What if it rains? You come back. What if you don’t have TSH 20,000? You don’t go. We didn’t have the heart to ask the other questions.

Nhembo is only half-way to the edge of our territory. Chagongwe is the furthest point, another 20km on a worsening road, and then up the mountain. Our ambition is to reach out to villages like Chagongwe, and begin the conversations that might eventually lead to maternity care at last being available to their women. It will begin by sending out a (Maternal-Child Health) Community Health Worker for talking and listening: What happens at the moment? What do they feel that they need? Who are the leaders? Who the potential health workers? We need to meet the TBAs and get their view on the past, the present and the future. There will be no blueprint that tells us how to engage, how even to begin, except simply to start the conversations.

We can promise nothing as yet, but we have hope. Chagongwe, for instance, is one of the communities that Hands4Africa is intending to reach, ultimately with economic opportunity, transport and education. If we can gradually blend health into the mix, then perseverance might lead us to local solutions. If, at the same time, we begin a Clinical Officer training programme at Berega, then we stand a chance of being able to deal with the wave of work we unleash.

The Clinical Officer training programme raises for me an important philosophical question. How much do we bring in wazungu? (Europeans are called ‘Wazungu’. Originally a term of mixed respect and awe, it now means something between ‘people in shorts who forget to greet you, and then ask to take a photo’; and ‘people who turn up to meetings on time, in a bad mood’.) Post-colonial Africa gradually realised that the popping in and out of wazungu could do more harm than good. Deeply caring figures of authority dictating the right way; intolerant tolerance; creation of dependence; blurring of identity; cajoling by the culturally insensitive yet well-intentioned; then suddenly an exasperated absence, and a regression to the mediocre. The culture clash has not been all one-sided, and of course those oppressed in the past by colonialism have sometimes exaggeratedly resented the intrusion of the erstwhile oppressor.

But are we emerging into a new day? Post-post-colonialism? A generation has passed, and it seems to me now that we both know who we are. I look at the wealth of talented, healthy Baby Boomers in England, the very ones who marched streets in their youth to protest at the colonialism of their fathers. Or at the very least listened to music that their parents disapproved of, whilst under the influence of things their parents disapproved of. Are we not now all on the same side? Well, that may be a little naïve, but I’m OK with naivety. When we have the Clinical Officer training, then, can wazungu of various disciplines take it in turns to come over and enhance the training, as long as the base is solidly Tanzanian? Here, they really want it. Can English-speaking primary teachers not come and help in Mama Liz’s school for a month or two? She really wants it. I think we might be ready for a spot of post-postcolonial-wazungu-ism.

With regard to this particular mzungu, however, my impact, as measured by body weight, is now once more on the decline. Having been boosted by the culinary dexterity of Dan the Mighty, I am now thrown on scarcer resources. Thankfully, Sion is still there, and last night conjured an impressive lentil stew from the unlikely ingredients of lentil, and stew. But he works very hard and cannot always be looking out for me. As I sit at the desk all day writing this, I am painfully aware that my ischial tuberosities are protruding through my flesh, and impaling themselves on the chair. Let me have bums around me that are fat. Sleek-bottomed bums, and such as pad the seat. My buttocks have a lean and hungry look. They ache too much. Such bums are dangerous. (If you don’t understand that last bit, ask someone who went to school when they still had inkwells.)

On Wednesday, then, having missed early breakfast, I came back late morning and decided to whip up a Spanish omelette. Well, let’s say something in between English and Spanish. A Santander Ferry omelette, may be. Anyway, it had some onion in it, as well as other traditional ingredients such as egg. I was proud of myself, and served it up on our last piece of brown bread.

I particularly needed the nutrition on Wednesday, because we had the follow-up meeting to last week’s, on making a Charter of Expectations, to set standards for working in the hospital. I have said that I am naïve, but even I do not believe that a magic new day will dawn tomorrow, and dissolve the problems of the past like morning mist. A charter of standards will not create excellence overnight. But what is surely true is that without it, we will remain in the dark. There were too many examples this week of the nocturnal insufficiency of current practice: delays; casualness; tolerance of the unacceptable; death as a travelling companion. And, on the other hand, there were many other examples of diligence, caring, and dedication in sometimes the most depressingly desperate of circumstances. As I write this on Saturday night at 8 o’clock, more of the senior staff are in the hospital than are at home.

The excellent news is that on Wednesday we agreed, including all of the management, that we would indeed  take a charter of standards to the staff. We would indeed sign up to a charter, however battered and tattered, of minimum standards. The amazing Sion, I hope, will gently, warmly and persistently be trying to make the children’s ward a showcase.  I cannot imagine anyone more suited for the job. (Aided by another worthy mzungu – David Curnock, who comes next month!)  We need plenty of others as naïve as we are to see it through.

(For posterity, I will load a copy of the draft document onto a separate blog page. It still needs to be modified by staff. Much more, it still needs to have any effect. But at the worst, a future mzungu coming here in a decade or two might be saved the trouble of writing another one.)

The final mzungu to mention is Marjan, who arrived on the scene from Belgium, via four months in Ethiopia. Marjan is a lab person, and in just a few days, has opened up for me a whole new vista: lab staff on ward rounds, who help, advise, and then quickly give you answers to the questions you might have had. What a resource. Like Dan, she is just here for three weeks, but is shining like a light.

The future then, is beginning to take more shape. A hospital where death is unwelcome. Caring wards where good work leads to fewer problems. All joining together, including wazungu, in the shaping of this, and in the development of clinical officer training, to root deeply a culture of learning and striving.

Then, for mothers and their babies, we will begin outreach to the unreached villages, and invite cooperation. We will invite them to deliver more safely in our safer hospital. We will go back with them into the community, and help ensure that their babies grow into healthy children. Within five years, we hope that the mothers of those villages will have other uses for their chickens.

PS apols for the delay and lack of pics, which will follow – the internet link is 1KB/century

Laurence Wood

email.lozza@gmail.com