For reference: Core Clinical Standards for regular monitoring

This is an extract from the minutes of a hospital meeting in response to the recent inspections and report. In those inspections, it was discovered that the culture on the wards makes it hard to be diligent, as the fall-back position has grown to be one of inactivity.

This is not the same as maliciousness or deliberate neglect, but is part of a wider weariness at the seeming inevitability of death, against a background culture which lacks proactivity and initiative.

These standards are simple enough for regular inspection, and the intention is to ensure that those few staff who regularly fail to meet them will not continue to work at the hospital:

"In the meeting we had between the doctors, nursing staff and managers last week we agreed that the following core standards must be adhered to as a matter of urgency:

1. Staff must be in work when they are supposed to be.

2. Vital signs must be checked and acted on if abnormal (twice a day unless otherwise specified).

3. Drugs must be given if prescribed, or discussed if staff are unable to give for any reason.

4. Doctors must see the patients (three formal ward rounds a week as an absolute minimum, but that sick patients should be seen every day, or more often if necessary)."

18. The Samson Dilemma. (The limited power of baldness.)

This month I met a wonderful and impressive couple: Dr Ahmed Ali and his wife Elizabeth. Ahmed is on his way to Berega, for a two-month stint as Obstetrician in Residence – the first of what we hope will be many journeys. On the next visit, Elizabeth also hopes to go, and her midwifery talents will be greatly valued. Inspiringly, they have chosen to close the door on very successful UK careers, and to spend the next phase of their lives making a difference where it is sorely needed. 

(When I was young, I might have referred to this as the ‘twilight’ of their careers. However, now that I myself am not just at twilight but hurtling towards the setting of Venus in Capricorn, this couple’s careers seem positively early afternoon by comparison.)

Of course when we met, Ahmed’s mind was full of the last-minute preparations. These are all the more important when the trappings of developed-world comfort and convenience are not likely to be available in the place to which you are headed. For instance, this is what a shopping mall looks like in Berega:

It would be fine for buying sacksful of the more indigestible parts of the faba bean plant, but expect a puzzled silence if you ask for a cappuccino-frother plug-in for your iPad.

When going through the list of things to ensure to take, (phone; charger; kindle; iPad; Sanatogen; etc), it transpired that Ahmed, (in his words), needed to “join to the present to go to the past”. He had, it seems, been living in the late twentieth century, when books were made of paper, phones were designed for speaking to people, and GPS was a Gammon and Pineapple Sandwich. Suddenly, he now had to equip himself with the electronic accoutrements of 2014, in order to spend a couple of months in what for most of the rural Tanzanian population, (for health purposes at least), is the eighteenth century. Ironic.

When I think of it, though, I am not so sure that the analogy is a perfect one. They had blankets in the 18^th century, but Berega has no blankets, nor good food, nor comfortable beds. Equally, three hundred years ago, they had no anti-malarials, no vaccines, and no antibiotics; but the presence of these modern miracles in Berega has not compensated for the dismal conditions in which many children are raised. With an under-five mortality of 10%, and maternal mortality approaching 1%, Berega’s territory has not moved on far from Walpole’s England. In the villages, the reason is clear: little has happened in the intervening three centuries to make a difference.

In the hospital itself, however, we might have hoped for better. Meagrely equipped though it is, it should nevertheless be ready deal at least tolerably well with the majority of life-threatening situations for mothers and their children.

In the past, to be honest however, clinical standards have been simply too unresponsive to the many fillips that they have received. (Thus my reluctance to kick off the first year of ‘EMBRACE’, until we are sure that we will be bringing women into somewhere safe and effective.) However, with the arrival of Ahmed, a new champion, hopes are high. This is particularly so, as he is in fact the latest in a whole bunch of champions. (Champions, it seems, are like buses – you wait ages for one, and then three come at once. Or in Mexico, seven.)

There are some interesting parallels, by the way, between the burgeoning help in Berega, and the Magnificent Seven. The most obvious is that both Yul Brynner and I prefer to leave our scalps open to the fresh air, rather than choking them with cultivated keratin. Both of us recognise, however, that baldness alone cannot help save a village. And for all the immense efforts of Isaac; Stanley; Abdallah; Sion, Brad/Hands4Africa; John, Tony, and the Diocese of Worcester / Mission Morogoro; Gary, David, Mike and the amazing worthies of BREAD; my good self; and others too many to mention; the hospital has still been struggling in many ways, not least in relation to clinical standards. Nevertheless, each year the lives of many are saved – lives which, without relentless hard work, would have been lost. Eclampsia and Haemorrhage and Malaria and Malnutrition and the rest of their deadly crew still regularly raid and kill. They are mainly fought off, but more could be done to deter these bandits.

Now, suddenly, opportunistically, the Magnificent-Seven-effect is beginning to kick in. (You may know that the story was based on a sixteenth century Japanese samurai myth. The idea, however, is as old as story-telling itself: that from an extremely beleaguered position, some fickle-finger-of-fate-ing leads to a burgeoning wave of powerful help, and the baddies are vanquished. I, for one, believe that the Finger of Fate is not in fact that fickle, and that the extraordinary constellation of heroes gathering around to help, are not here by chance alone.)

Nevertheless, it is about as unlikely a story as ever inspired Hollywood. Even I do not know the full details. (For instance, I genuinely don’t remember how I got involved with Berega. I remember making the vaguest of enquiries in response to an ad about a short spell in Ethiopia. The next thing I remember is buying peanut butter in Dar Es Salaam.) Anyway, to cut a long, long story short, a year ago, Sion was headed for a job with MSF. By a hugely unlikely life-upheaving coincidence, four months later he had begun a year’s job at Berega. A veritable Steve McQueen of the stethoscope, he began knocking off baddies on every side.Then came myself; Dan; Marjaan; Blanché; and the recurrent hero, David Curnock.

More recently, Ann Kang, who works in the hotel industry, met Sion in a random bar in Zanzibar. Utterly incredibly, shortly afterwards she had begun a three months' stint working in Berega. Her legacy includes not only the first ever monitoring of clinical standards, (accomplished with the new Assistant Matron), and too many other works to name, but also the gathering of tens of thousands of dollars to sponsor village children through education – the single-most determinant of health in the world.

Check out her amazing story at http://www.anninberega.blogspot.co.uk/

And Sion’s at: http://doctorwoctor.blogspot.co.uk/

The story keeps on expanding. The medical establishment had recently been up to three: Olivia Vandecasteele a Belgian tropical medicine expert, and Sander Wever, a Dutch head of an Emergency department, found themselves drawn into the whirlwind. What a difference to have these experienced professionals dedicating themselves to the cause.

Most extraordinary of all has been the expansion of KOFIA. From the modest hope to knit 50 hats to send a message of love from Guildford to Tanzania via Basingstoke, Blanché Oguti and Debbie Donovan’s efforts have blossomed to an impossible extent, where many people in many countries are now knitting for Africa. With the arrival of the wonderful Nina Oakman offering herself as KOFIA’s link in Dar, they are set to begin helping poor women throughout Tanzania to tackle the deadly problem of neonatal hypothermia. (By the way, although sending knitting across the world sounds a little old-fashioned, and although it may seem wiser simply to send money and commission some local wool-taming, success is not measured only in financial value. Thousands of people are finding not just purpose but an outlet for their generosity and good will towards the plight of the needy. KOFIA hats, blankets and clothes are a symbol of an increasing readiness to share responsibility, in this small world in which we cohabit.)

Meanwhile, as ever, Brad and Hands4Africa have been beavering away, and working towards a community solution that will provide a platform on which health services can build. Recently, Julie Angulo has worked tremendously hard to put in a bid for a grant which will really help the EMBRACE project to pluck some of the poorest communities in Africa from the eighteenth century into the present. We have been holding off with the implementation of EMBRACE until we were happy that Berega clinical standards were sufficiently good. Now, we are close to being ready to plan the next steps.

And so to the future: In order to keep the rapidly expanding story in a single place, I am going to give over this blog site to regular guest bloggers – anyone with a story to tell as to how things in the territory are progressing. Whenever a blog is posted, I will put it on the Berega wall, so please like it, (and get others to), and you will be told this amazing tale as it unfolds.

https://www.facebook.com/pages/Berega-Hospital/185336328323947

Additionally, using my Berega facebook identity, I might have invited you as a friend, and will also use that, (once my grandchildren have grown up enough to be able to teach me how), to keep you posted.

When I was about forty, my scalp hair began falling out, and, like Samson and Yul Brynner, I was quite upset about it. Little did I realise then that the power also flows through teachers’ chalk, random drinks in Zanzibar, and woollen hats.

email.lozza@gmail.com

Guest post Sion Williams

I first met Sion Williams when he came round to my house as a beardless youth, to chill with my daughter Mollie. Neither of them were doctors then, but with school-friends they were making a film - a comedy about elves, if I remember. Sion was the hero elf, and Mollie one of the heroines. I don't think it ever won the Palme D'or, but there's still time.

About this time last year, Sion came round to see Mollie who was visiting, and he got talking about his plans to work for Medicins Sans Frontieres. (In search of a Palm Door?) A fateful conversation ensued, and by May of last year, he found himself as the only doctor for 100km in any direction, in charge of the children's ward at Berega Mission Hospital. 

Eight months later, countless people, both in Tanzania and in other countries, have been influenced by this unassuming warrior for the right of children to survive.

Read his whole story at:

http://doctorwoctor.blogspot.co.uk/

Below is a sample:

A UK junior doctor lost in the African bush

Thursday, 31 October 2013

Weighing babies and tipping the balance on malnutrition: Under 5 mortality in rural Tanzania

Silent, screaming grief mixes with the hot stagnant air. I stand beside a rusting hospital bed holding a kitenge. These vividly coloured wax printed sheets adorn Tanzanian women everywhere, as skirts, headscarves, baby carriers. Today, the one in my hands is a shroud. A grandmother stands next to me. She cries as I pull it over the cold, motionless face of a three month old baby.

The day started badly. I am frantically busy as I round the hospital alone. All the doctors have been ordered to attend a government seminar. We were informed of this by text message last night. If I wasn’t here, I’m not sure who they would have expected to see the patients. I visit Elena, a 17 year old girl with typhoid. The disease is endemic here. People do not have well-dug toilets and raw sewage filters into rivers. They cannot spare firewood to boil river water to kill the bacteria before drinking it. Typhoid thrives. This young woman caught the bug, got sick, and her bowel burst open inside her. Last week we opened her abdomen to scoop out the infection and repair the hole. It was a mixed success. Her life was saved but several days later the infection came back and her wound burst open. She now leaks fluid from a small gap in the surgical incision site. I examine her and clean her wound. She is a shadow. She has the build of a skinny 10 year old girl, and the face of a much older woman. Her skin clings to her. Every vessel, bone and muscle is visible. She sits uncomfortably on her bed staring at the wall. I encourage her to eat and write some more antibiotics.

Her grandmother is speaking fervently in the local language, Kikaguru. She is clutching a bundle of blankets, and starts to cry. A student translates- Elena has a 3 month old daughter which she is unable to feed because she has stopped producing breast milk. Her family didn’t know what to do. They fed the baby with unpasteurised cow’s milk, leading to a diarrhoeal illness with fevers of 42 degrees. They have since been feeding with over-diluted formula milk. A tin designed to last three days is almost full, one week on. They can’t read the instructions and want to ration the expensive milk. I flick through the case notes and no one in the hospital seems to have offered them any other advice.

I carefully unwrap the child. She is unconscious, thin, floppy, has oedema from malnutrition, and cannot feed. Her lips are dry and cracked, covered by the white spots of oral thrush. I carry the fragile, limp bundle to the children’s ward where we give her glucose, antibiotics, and a small amount of fluid through a vein in her scalp, wrap her up warm, and cautiously drip formula milk through a tube in her nose. She carries on deteriorating, and despite resuscitation dies several hours later.

I inspect the body. It is unspeakably terrible to see a still, lifeless baby. Is she at peace? I close her eyelids. She almost looks serene. Her great-grandmother unwraps the kitenge from her shoulders and hands it to me to wrap the baby. I say sorry. “Pole, Bibi”. I’m sorry, for my failure, for the failure of the hospital, for the cruel workings of the world which have led to you wrapping a funeral veil around your great-granddaughter. Bibi you have been crying since yesterday, and you feel this is your fault for not caring for the baby well. I feel angry, sad, and nauseous all at once. It will take me a while to get over this one. I know that you will never really recover.

They say that two wrongs don’t make a right. Using the same perversion of moral algebra I guess you could also say that two rights don’t correct a wrong. But some days working in this hospital is like wading upstream. Sometimes you have to remind yourself of the successes just to keep your head above water. This week we are nursing two children back from malnutrition. Slowly they are improving. My resources are limited. I cannot afford the expensive malnutrition feeds the WHO recommends so I make up my own, using powdered milk, sugar, oil, cereals, and added vitamins and minerals. Children are living.

Malnutrition is the scourge of children worldwide, and contributes to a staggering 50% of deaths of under 5s. About once a month we see a case of the most severe type- a skeletally thin marasmic child, or one swollen and lethargic from kwashiorkor. Even with the best treatment, 1 in 3 of these will die. But collectively the biggest burden is from chronic rates of mild and moderate malnutrition. These children would otherwise survive an episode of diarrhoea or measles, but deprived of the building blocks for health- vitamins, minerals, and calories- the balance is tipped against them. The problem starts with a diet of carbohydrate rich and nutrient deficient staples like maize, and is worsened by drought and inefficient farming methods. A malnourished child is more likely to get an infection, which in turn worsens their malnutrition, leading to more diseases and a deadly downward spiral. The solution starts with prevention. This year’s G20 focussed on optimising agriculture in Africa as an essential and enabling step out of the poverty trap. The average modern African farm is less productive than an American farm 100 years ago. The continent is rich with agricultural heritage, land and willingness to improve. Something, soon, must tip the balance and unlock this potential. Maybe this will be do-gooders from abroad. I suspect the important change will more likely come from within.

I end the day covering the outpatient department. My last patient is a happy, drooling, chubby-legged 8-month old boy. I joke with his mother that he is very fat. She glows with pride. The child is in fact not overweight, but merely in the statistically permissible upper limit of what the WHO would call normal. But after my 4 months here, and weighing hundreds of sick children, this is one of an exclusive handful which have either achieved or mildly exceeded their expected weight. He has pneumonia, but no danger signs. Because he is well-nourished he will likely weather the illness well.  He escapes home with a bottle of antibiotics and a follow-up appointment. I wave goodbye to him, and he grins happily, tied snugly to his mother’s back by a colourful kitenge.

Guest Post - Ann Kang

Ann has just left Berega after a three-month spell making a difference.
Ann, who works in the hotel industry, a few months ago was having a drink in a bar in Zanzibar. She could hardly even feel the breeze of Destiny as it blew her towards Sion, an unlikely saint, sitting by himself in a corner.

A few months later, she herself was unlikely-sainting away in a remote part of Africa, having an enormous impact on the lives of those impoverished people.

Read her full story at:
http://www.anninberega.blogspot.co.uk/

Here is a starter:

Heading towards the finish line....and how it all started..

My 3 months in Berega is coming to an end. I can't believe how quickly it's passed and I can't believe I made it! Those of you who know me well, will know that I never thought I was the type to go living in a rural village, doing volunteer work for 3 months. In a place where there's lots of bugs, scorpions, snakes, and livestock all around me. A place where you worry about water running out and feel very lucky to have satellite Internet, even though it's the slowest Internet ever. A place where time seemed to have stopped and people struggle to be farmers and being a 'peasant' is an occupation you write down on a form.
I grew up mostly in big cities. I was born in Seoul, grew up in Jakarta, Hong Kong, Chicago, and recently lived in Tokyo, Dubai/Abu Dhabi, Shanghai, Suzhou, Shenzhen, where the smallest city I've lived is probably Dubai, a population of 2 million and the largest is probably Tokyo with almost 30 million people in greater Tokyo.
How on earth did I ended up here in Berega a population of somewhere between 8000-10000 people...

Many of you have asked me how I ended up here and why I am doing this and here is my story.
Jon and I travelled to Tanzania in September to spend some time with our friends who had just moved to Dar es Salaam to teach at the international school here. We were in Dar for a week or so when we went to Zanzibar, an island just off the coast 2 hours by ferry. On our last night in Stonetown Zanzibar, we were at the night market there trying some local seafood. I noticed Jon talking to another foreigner and he introduced me. "Ann, this is a British doctor volunteering in a small village here in Tanzania." I remember thinking..'yeah right, a volunteer doctor...ha!' Because until then, I've never met anyone, a doctor especially, who chose to live in a rural village in Tanzania for a year! Anyways, I spoke a little to this 'doctor' and he seemed harmless and lonely and he was alone so we invited him to go with us for a beer, just down the beach. We had a couple beers with Sion and he told us a little about the village he's working at, Berega.
As we were leaving, we exchanged our email address and went our ways. The next day he sent us a nice message thanking us for paying for his drinks and sent us a link to his blog. When I got back to Dar, I read his blog and was pretty shocked at what he's written and I couldn't stop thinking about it. I read it out loud to Jon and then to Elif and anyone who would hear me. I kept wondering how this could be true....how people had to walk hours and hours to get to the hospital, where it wasn't uncommon for mothers to die giving birth, and people had to carry the bodies home on the back of a motorbike. Things that I remember reading about somewhere, but never imagine it still happening all around. I told Jon that before we leave Tanzania, I would really like to visit this village. We just had a few days left and quickly arranged to meet with Sion, as he was on his way back from Zanzibar finishing his vacation. We met him and Liz who's the American teacher who's been living here for 3 years, and took the 6 hour bus together to Berega. I remember being excited to visit this village and also scared at the same time. Sion told us that he had no electricity and what about malaria? We weren't on any medication as this trip to Tanzania was planned a few days before we arrived. I tried to bring some food but what were we going to eat there? Well, to make a long story short, our 2 day visit was wonderful and we had a chance to visit St Mary's school where I ended up teaching at, Sion gave us a grand tour of Berega Hospital and the grounds, as well as the village itself. And as we were leaving, I remember thinking to myself that I would really like to come back. I wish I could do something meaningful like Sion and Liz have been doing. It would be difficult to commit to something long term here since Jon just got a job offer in Abu Dhabi and we were moving there, but even for a few months of my life, I would like to do something good....

So here I am looking back at how it all started. Besides anything I have done here, I have to say that one of the most personally meaningful thing that I have achieved is meeting a true friend for life! And for this I have to dedicate this post to my dear friend Sion, the true volunteer doctor who is giving a year of his life to work at a village in Tanzania. If it wasn't for him being such an inspiration, I would not be here and for those of you who have not yet read his blog, please go ahead and read it (www.doctorwoctor.blogspot.com)
Living next door in this rural African village for 3 months, I'm glad I got to know him the way I have and he's one of the most remarkable, noble person I know and will always admire him for his passion and his warmth and genuine care, the many lives he's saved here, and most importantly thank you for being my friend.
I will miss the evenings; our discussions and frustrations on how we can improve things here, the depressing days talking about poverty and death, the happy moments celebrating the small successes....and the many drinks in between. Whenever I had doubts about the work I'm doing or crying over the sad reality here, you've always encouraged me and provided moral support...although you are doing so much more than I have ever achieved here. I have learned so much from you and you will always be part of my memory of a great adventure here.
Thank you Sion, this one's for you! Oh and happy birthday on Sunday!
We're going to party Berega style! =)

For reference: Checklist for Tanzania volunteering

1. Visa to visit Tanzania

The form is straightforward:

http://www.test.tanzatrade.co.uk/images/stories/visa_form-2013.pdf

The caveats are at:

http://tanzaniahighcommission.co.uk/index.php?option=com_content&view=article&id=49&Itemid=55

However, actually getting the visa proves a problem if you are going for a couple of months. You need a two-month Visitor’s Visa', but it is only valid for three months. However, the High Commission in London do both same-day overnight processing, (for a fee!), and so the best plan is to go there with a little less than a month before travel, and do one of these rapid-turnover options. Don’t forget your passport!!!

As you will have booked flights long before this, it leaves to chance that they might refuse. However, refusal has not been a problem.

2. Registration with the Tanzania Medical Council

This is only needed for doctors who plan to do more than ward rounds. Given the fact that the hospital is run without doctors, then going on a ward round with one of the staff and giving your opinion, although technically professional, is not something inappropriate, and nor would it land you in jail.

However, doing on-call, or assisting at operations, or signing prescriptions, or making the go/stay/how to treat decisions in outpatients, these are all real doctoring. (And all leave your indelible imprint behind.) It is only right that the hospital should expect people undertaking such activities to be registered, as their way of quality-assuring the doctors.

Again, the form seems simple:

http://www.rotary.fi/images/stories/RDBF-julkinen_aineisto/Ohjeita-laakareille/medicalregistrationapplicationform-fill-in.pdf

It does, however, need notarised copies of the usual things. Additionally, the host institution in Tanzania should send a letter to the medical council, confirming that they have invited you to come. You need to send all the documentation in advance, but without the fee.

After you send everything, there will probably be no response. You can send a reminder which may also be ignored. If you do manage to get the IBAN & SWIFT codes, then send the money, (in dollars!). You have then done your part, and I would advise leaving to the hospital to sort out with the Council the certification.

If it gets to the day of arrival and you still have not been able to pay, then before leaving Dar you and the driver, (whom you will need for moral support!), will need to go to the Council and complete the payment. This is the accepted norm. Once you have paid, your certificate will one day appear. Don’t worry.

3. Guidelines for Emergency Obs Care in Tanzania

There are no agreed guidelines – each initiative has its own. Look up on line, and down-load full copies of what you need before you go. Check out esp the WHO:

http://www.who.int/publications/guidelines/en/index.html

Also, eg:

http://www.who.int/pmnch/countries/tanzaniamapstrategic.pdf

http://www.ihi.or.tz/

Life Saving Skills Manual – Essential Obstetric and Newborn Care

Nynke van den Broek Publication Date: Sep 2006, revised June 2007. ISBN: 978-1-904752-28-8

http://www.bloomberg.org/press/releases/2012-10-02-maternal-health

4. Before you go

Double check: Visa. Passport with at least six months. Health insurance including a policy document to take with you – previously scanned and sent to your host, just in case! Spare passport photos in case needed; belt or secure system for money; debit cards; laptop and big memory stick with all your stuff on both; camera; also web cam for Skype etc; camera charger and download system; mobile phone and charger; small rucksack for day-travelling; maps; types of tea you might like; kindle or e-reader/ charger /light; fly swat; music on your devices; traveller's back-pack water-container for journeys; torch /batteries.

Also, think about small presents for people you might visit - eg English coasters or mugs, old mobile phone, balloons for kids.

It is best to take a valid Yellow Fever certificate, and essential if you stop over in a yellow-fever country. Don’t give any cause for any official to ask for a bribe!

Tanzania is 3 hours East (ahead) of GMT.

5. Things to buy on arrival

You may arrive either at Dar, or, if working in the north, Kilimanjaro. Dar and Arusha are big cities, and for much of what you need it is cheaper there. For instance, any medications can be bought from pharmacies - eg buy.

Other things you might want to think about buying in Dar, (or Arusha, etc), are:

SIM for your phone or ipad

Malaria prophylaxis – Malarone or Doxycycline, not Mefloquine.

A course of fluoroquinolone-style antibiotics for dysentery – less than £2. Buy one for each month you will be there!

Antihistamine or hydrocortisone cream

Anti-bacillary-dystentery antibiotic pack

Paracetamol

Anti-mosquito spray

Mosquito net if going anywhere which is not equipped with them 

Spare torch(es) and batteries - perhaps plus candle and lighter backup

Tissues, soap, toiletries

Universal sink plug

Many pens, and paper

Any luxuries or food pre-requisites

6. Food

People are poor, as is the food. Maize porridge is the main staple, (or rice for the relatively well-off), and meals might be 95% staple with a sprinkling of cheap and stringy meat. However, of course you can buy meat, eggs, (and amazing fruit and veg!), etc in towns. 

However, if you like your protein, you might want to buy some peanuts or other storable source in Dar, and if you have any food fads, then prepare in advance to look after them!

7. Money

Most rural settings will not use debit cards, and so cash is important. (Or a mobile phone with a Tanzania SIM that you can use to buy a sort of bit-currency.) The local currency is Shillings. £4 = 10,000 roughly. (So when seeing a Tz price, knock off four zeros and multiply by four.)

The best place to get Shillings is at the airport kiosk - it is much quicker than in banks.

You will also need $USD - no notes before the year 2000, because of forgeries. When you pay for official items - and many unofficial ones - it seems that USD is the currency of choice. You have to balance how much to bring with the security of carrying large amounts of cash. Tz is a safe country by African standards, but (self-evidently), don't take out a great roll of cash and peel off $50 bills when paying for something!

8. Swahili

There are many sources on the net. It is best to get those with a Tanzanian slant, where any preference is available. I have also written a guide to the structure of the language, which if you like I can send you. (email me at: email.lozza@gmail.com)

 9. The culture

If you have ever worked in Africa, you will know that things do not work there as they do here! Other values operate – for instance, politeness and greetings count for much more; family and relationships are more important than tasks; communication is so polite that it does not always say what you think it is saying; groups are more important than individuals; possessions tend to be shared; hospitality is spontaneous and very inclusive; etc.

If these things are not familiar to you, far and away the best way to get a feel for them is in the book, ‘Foreign to Familiar’, by Sarah Lanier. (ISBN 1-58158-022-3) You can read it in an afternoon, and it is a vital preparation for anyone seeking to be at home in an African culture.