26. Teacher’s Recipe

26. Teacher’s Recipe

21st May 2014

Take 1kg of strong bread flour with 625ml of warm water; add a little sugar and touch of salt. Mix them well, forcing the ingredients to intermingle fully. Bake until golden brown, glazing with honey when nearly ready.

You have just made yourself a lovely golden brown brick. Perfect for building biodegradable dwellings, but not so good to eat. If you wanted bread, you missed out the yeast. There’s just a little of it, but without Saccharomyces – and some careful and sensitive handling – the dough never quite manages to make the miraculous journey to loaf.

There’s got to be a metaphor in there somewhere.

On a related theme, this is a recipe from 1962: Take 10 million people in a massive country with 20 main rivers; add a little foreign investment and a touch of natural resources. Blend in Julius (‘Teacher’) Nyerere. Intermingle, with firm, careful and sensitive handling, glazing with a new Constitution when nearly ready. What you get is a mixed legacy, but for all the difficulties and disagreements, it is at least a country still at peace two generations later. More impressively, it is a country where the tribes and religions often work side by side. 


  

Corruption is there, but not on Zimbabwean or Nigerian scale. Death is often at the door, and poverty is desperate, but that owes much to the lack of investment and infrastructure. (And to Africa’s most dangerous animal – the mosquito. Mankind is only Number Two.) Muslims aspire to send their girls to school just as much as Christians do – though in rural areas, lack of just about everything too often precludes it.

By contrast, in neighbouring Zimbabwe, Nyerere’s contemporary Robert Mugabe is presiding over a country with 8000% inflation. Prostitution has become a common means of paying for what the developed world takes for granted – education, opportunity, even food. Opponents are crushed ruthlessly and inter-tribal violence is a way of life. For a week-long wedding for his daughter, Mugabe recently paid out what would have been a year’s wages for more than a thousand of his countrymen.

Leadership. Two very similar countries: two very different directions. Is it too much to say that leadership is at the heart of all collective success - and atrocity? (My family might disagree in relation to the latter, with the memory of some of my culinary atrocities still emblazoned on their tonsils. I would point out to them, however, that  leadership was not the problem. There was no heady rhetoric. There was no call-to-arms. No-one marched on the Presidential Palace. Just me, the internet, and the misreading of the recipe. Several times. Even my family must admit that some good things came out of it, though, such as the widespread acceptance now that curry paste has no place in sweet-and-sour salmon en croute with mushy peas.)

Success, then, depends not just on the right recipe, but on the person who catalyses the entire process. Berega hospital has a wonderful leader - Rev Isaac Mgego MBA. Like Nyerere, he came up from the grass roots of the country. He was the first in his family ever to complete high school and the only one in his district ever to make University. Indeed he is one of the few from his village who was even literate. He had to wait for his education until the responsibilities of being a healthy son afforded him the time to go and burn charcoal to pay his way. 

Now he and Dr Abdallah - Anglican minister and Muslim medic - together try to lead the hospital's response to the health needs of a quarter to half a million people, spread over a vast area, with almost no resources. In a continent of much uncertainty, one thing is sure: without them, Berega would fizzle into the same sleeping sickness which afflicts health services in many rural areas.

So my question is this: out in the community, who will be the one to muster the fight against maternal and child death? Where is the leadership going to come from to tackle the multiple and complex deprivations suffered in Africa's villages? We know that the way ahead lies with empowerment of women, starting with nurturing the development of women's groups. But without leadership, nothing will happen. Who will be rural Tanzania's champion?

The answer came to me as I wrote the question: to lead the fight against the problems of rural African women, we need a rural African woman. Someone who has had to carry precious, dirty water many miles. Someone who has gone hungry to feed a family. Someone who knows what it feels like to watch the motorbike come back with the mother strapped on and the baby poignantly absent.

Money and resources have been what traditionally held us back. However, with the widespread involvement of many good people in EMBRACE / TUSHIKAMANE, perhaps in future the dough will not be the issue. Teacher Nyerere knew the recipe. Let's start looking for the yeast.

25. Sion's Guardian piece on malnutrition

12th May 2014

The EMBRACE programme is aimed at saving the lives not just of mothers, but of their children. In rural Tanzania, more than 10% of children do not make it to their fifth birthday. One key reason for the vast difference from developed countries is because malnutrition in rural Tanzania is the norm.

Even the kids who look healthy often mainly subsist on porridge, and have complex un-met nutritional needs that make them considerably more susceptible to infection.

When the girls grow old enough to have children themselves, they may be already anaemic and undernourished, and unready to face the stress of pregnancy.

Fixing malnutrition, then, is at the heart of saving lives and empowering mothers and babies.

Here is Sion's piece for the Guardian (UK) dealing with the issue:

For the past year I've been running a children's ward in rural Tanzania. Every day I treat severe acute malnutrition (SAM), a condition responsible for over half a million deaths in under-fives each year. These children are either emaciated, weighing less than 70% of what they should, or have oedematous malnutrition, where their legs, and in severe cases, whole bodies, become swollen.

Without calorie-dense micronutrient-enriched therapeutic foods up to two thirds will die. Managed properly, even in a basic setting like ours, we can reduce this by over half. Actually getting hold of the therapeutic baby food is the biggest challenge of my job, and one faced by frontline healthcare providers across Tanzania.

This week I am called to see Faraja, a four-year-old girl with SAM. She is weak from a combination of starvation and infection, and cannot swallow without food going into her lungs. I inject antibiotics and place a tube through her nose to drip milk into her stomach. It is a precarious balance between giving enough to prevent fatally low blood sugar, and avoiding stressing her fragile metabolism and undernourished heart. Two days later, despite regular feeding, the infection is overpowering. I give CPR. It is a formality. Faraja's file joins a pile of three others on my desk, all children lost to malnutrition this month.

Faraja had more chance than most, arriving when therapeutic foods are in stock. The World Health Organisation recommends two pharmaceutically prepared formula milks, F75 and F100. These contain a combination of powdered cow's milk, sugar, fat and micronutrients, specifically proportioned for a starving child's metabolism. By adding clean water you have most of what is needed to treat malnutrition. It is liquid, allowing us to give by tube to semi-conscious children like Faraja. The disadvantages are cost, and reliance on a supply chain. Within Tanzania, it is only available through UN agencies and NGOs.

Our three boxes of formula milk will soon run out, with no guarantee of replacement. We contacted the UN for assistance after seeing numbers of children admitted with SAM double in 2013, and then double again this year after floods destroyed crops and infrastructure.

Unicef runs a programme supporting treatment of SAM in our region, and the NGO prompted our regional hospital to supply us with therapeutic milk. We were told only three boxes could be spared. This is enough to treat two or three children for the six to eight weeks required to recover from SAM. This week alone we admitted two new cases.

Admittedly, the need is huge, and formula milk is not a sustainable solution in a country where nearly 2% of under-fives are severely malnourished. But it can help some, and failures of the government and UN agencies to distribute scarce resources appropriately are frustrating. When I visited the storeroom of the regional hospital to collect our supply, I noticed several unopened boxes which expired last year.

When formula milk is not available we struggle to make our own. The WHO suggests a cheap cereal-based alternative made from locally grown maize and soya. Cereals require cooking to be digestible and, like most hospitals in rural sub-Saharan Africa, we have no kitchen. We quickly realised the impracticality of asking nurses to burn charcoal on the ward to prepare feeds.

Most often, we use a more expensive alternative, mixing powdered milk with sunflower oil, sugar and water to approximate the pharmaceutically prepared formula milks. The ingredients require careful weighing by a nurse caring for a ward full of sick children. Errors are frequently made. Furthermore, we must find micronutrients to enrich the foods. A ready-mixed micronutrient powder is available, but only along the same supply chain as the pharmaceutically prepared milks. We substitute this with vitamin and mineral tablets. Some, like zinc, are easily found due to its widespread use to treat diarrhoea, but we cannot find the more obscure elements, like selenium, copper and magnesium.

The World Food Programme, Reach and Scaling-up Nutrition are working with the Tanzanian government to improve nutrition. There are good evidence-based policies to move treatment of stable children with uncomplicated SAM into the community, and feed with locally available foods. But there is little mention of how we should feed children with complicated SAM, like Faraja. They arrive unconscious, sometimes hours from death. Hospital treatment with easily prepared formula milk offers the best chance of survival. But where will this come from?

Ultimately, prevention is much more effective than cure. Feeding severe cases helps a few, it doesn't untangle the social and economic causes of malnutrition. The government and their partners will help many more by promoting breastfeeding, diversifying crops and fortifying food. But as a doctor the immediate concern is the person in front of you. For now, we will continue to make an imperfect difference trying to save children like Faraja.

• Names have been changed to protect identities.

Sion Williams is a doctor at Berega Mission Hospital, Morogoro, Tanzania. Follow @Sionkwilliams on Twitter.

24. EMBRACE / Tushikamane begins

12th May 2014

Sion’s EMBRACE project update:

The Embrace Project is all about reducing maternal and child deaths in rural Tanzania by empowering local experienced midwives and nurses to work with local women and village leaders. Through listening to the problems faced by local women, and in turn working with them on education, capacity building and removal of barriers to access care we are sure that together we can bring the maternal mortality rates down.

Today was an important first stage- we met with 3 village leaders from Tunguli: Abdallah Mngoya, Ehudi Sangali, Michael Bomphe:

Tunguli is an isolated settlement, far from the hospital, accessible only by crossing rivers in a 4 wheel drive. Or on foot:

We arrived, wary, diplomatic, gauging to what extent the leaders were willing to start a working relationship with us. We needn't have been cautious. On arrival they presented us with a list of ideas about how we might be most effective, and the best ways to engage the different ethnic groups in the area.

We discussed the project name- Tushikamane in Kiswahili. This means- we are in solidarity. Their similes broadened. "When can you start?"