30. In the Dog-house

For consumers of the annals of human endeavour, two memorable morsels ricocheted around the social media last weekend. The one you are less likely to have sampled is the sight of Queen Elsa pouring an ice-bucket over the head of a well-meaning but gullible ex-obstetrician:

https://www.youtube.com/watch?v=FBvbg3yeslo

The intention was to raise funds to stop mothers dying in childbirth; to give hope to communities in rural Tanzania; to help a part of the world where each village has ten children die every year:

http://yellowchuckchucks.blogspot.co.uk/2014/09/what-size-for-womens-groups-in-rural.html

http://yellowchuckchucks.blogspot.co.uk/2014/08/embrace-tushikmanane-where-we-are.html

It’s only a week on, and maybe these things trickle through slowly, (or maybe Threadneedle Street is scrutinising the destiny of such an exodus of bullion), but nothing much seems to be happening on the fundraising site:

https://mydonate.bt.com/fundraisers/embrace

(I suppose another possibility is that the Bank of England was waiting until Scotland Has Decided. It would be awful if they paid-the-bearer-on-demand-the-sum-of lots of Sterling, only to discover that the donor had been Scottish. A dreary process would then ensue, of trying to get the bullion back in return for the Scottish GrOats.)

The story more likely to have captured your attention was the burning down of the dog’s home in Manchester. The home is a sort of refuge for dogs, where they can find friendship; comfort; posts smelling of other dogs’ urine; and, if needed, counselling. It is a sign of a deeply sophisticated society that we care in this way for a species that has brought to ours so much in the way of comfort, unquestioning friendship, and chewed sticks. I have noticed in my short transit through Life on Earth, that a person who is kind to humans is rarely cruel to animals.

Looking after dogs, then, is a noble enough undertaking, and it would not have been surprising to have observed generous support after the home was tragically struck by such a devastating fire. What was more than surprising – even astonishing – indeed ‘Blairs-decide-to-retire-to-holiday-home-in-Merthyr-Tydfil’ level of unlikeliness – was that in just a single weekend, they raised £1.2 million for the re-building of the dogs’ home:

http://www.bbc.co.uk/news/uk-29204953

I know that my ice-bucket challenge did not tap into the same market, and I do not have the same appeal: Apart from the lower half of my face I am not furry. I do not have wistful eyes.

If someone throws a tennis ball, I am perfectly capable of almost completely ignoring it. I am not intrigued by the smell of other people’s trousers. If I find anything disgusting whilst walking through the park, I am neither tempted to eat it nor roll in it. I am allowed on the sofa.

I could go on, but I am conceding the point that I lack the canine X-factor. In a head-to-head fund-raiser between Lassie and I, to buy somewhere to rest our weary heads, the collie-dog would have the donors rounded up before I had even downloaded the Lottery’s “Fifteen Things You Should Know Before Applying For An Ageing Hippy Weary Cranium Residence-Enhancement Grant”.

But what would Lassie think about spending that amount on her home, at the cost of her owner’s life, and those of her children? If dogs really are a person’s best friend, would they truly want to move into million-pound kennels when, 5000 miles away, the young lads who would love to scamper with them are beset by malaria, malnutrition, infestations, infections, and tragedy; and who, too often, will never throw a stick again.

I do not exempt myself from this sobering reflection. What I have spent on our two dogs this last dozen years would have paid for many wells. For a school perhaps. For a land-rover ambulance. For many, many emergency C-sections, performed in poor light on mothers desperate to survive and see their child.

Where would we be, though, if suddenly we were equitable in the distribution of our largesse? Theme parks and cinemas would close down as pleasure-seekers found new comfort in sending their spare cash to the needy. The clothing industry would grind to a halt as we wore what we wore until it fell off our backs, giving the money released to the naked and the cold. Malbec producers would call an emergency summit in Mendoza, as I replaced my nightly nectar with enough dirty water to moisten my mouth.

The world is not fair, and never will be. For there to be wealth-sharing, there has to be wealth.

But, on the other hand, where would we be, in this tragically unequal world, if we closed our ears to the anguish of death and tragedy, albeit in distant lands? Where would we be if the cries of the suffering and the desperate never penetrated our cocoon? Where would Lassie be, if, knowing that all this was going on in the world, she accepted a millionaire’s kennel?

For me, dog-lover though I am, I know where I would be if I ignored humanity in favour of other species.

In the dog house.

Guest blog: Dr Olivia VandeCasteele

Role: A visiting doctor from Belgium

Last year, on the 20th of november, my partner Cédric and I arrived in Berega, to stay there for two months. 

https://www.youtube.com/watch?v=D9YBOYn10FA&list=UUcGPVMRnWyglSeIJ4sssvQg

Before I came to Berega,  I had just graduated as a General Practitioner and finished a degree in Tropical Medicine. Dr Sion Williams, who had been working here for a year, invited me to come and help in the hospital. 

In the beginning I was working together with Sion on the ward, particularly with women and children. After 2 weeks of adaptation I started working in the out-patient department where the 'clinical officers' examine and treat walk-in patients and decide who will be admitted in the hospital. 

These clinical officers are recruited either from nurse graduates or sometimes directly from secondary education – though often they will first have had to work for some year to find the money for their training. They spend 3 years in Clinical Officer training, which is mostly practical. I tried to learn how they work and tried to teach where appropriate (optimization of their clinical examination, broadening of their knowledge of differential diagnosis and antibiotics,…)

Although there were times when Sion and Abdallah had been the only medical staff here, during my stay we were working in the hospital with 3 European doctors, 2 Tanzanian doctors and 5 clinical officers! All the doctors and nurses are given a house on the compound . We were living with ‘the Europeans’ in a big house, with a huge kitchen and living room and several sleeping rooms:

In the evening we could go for a beer in the ‘pub’ – a small  hut in the village with an awning and chairs outside, that last year at last acquired electricity and a fridge!

Check out:

http://youtu.be/7XLrmd-qAGg

We bought our food in the little stalls in the village:

or at the weekly Monday market:

At weekends we rested, visited Morogoro and explored the surroundings of Berega. 

https://www.youtube.com/watch?v=cDGP2GJRWuA&list=UUcGPVMRnWyglSeIJ4sssvQg

We were invited to a Christmas party at the orphanage, with a great meal and a lovely performance of African singing and dancing. (The hospital has its own orphanage ...) On the evening before Christmas we cooked our own meal and celebrated together at home.  On Christmas we were invited to join celebrations in the village.

Cédric, my partner, signed up to do some community work. He works as a chef, and taught children at the local school how to bake during their summer break. He gave driving lessons to local women in the village. He also worked with a charity in the village called ‘Hands for Africa’by trying to make soap from local products, produced on the farm, and by visiting families in the village in order to give the children a chance to get a scholarship at the local English language school.

It was difficult to leave Berega. Sometimes I feel guilty that I only stayed for 2 months, that I didn’t do more for the village. You could work here forever, because it feels like they will always need doctors. And you need to get to know them. 

If you read this and you are planning to go there, I truly advise you to do so!!

29. Whatever ...

When I was a practising obstetrician, helping women to prepare for childbirth was an important part of the job. This especially applies to the birth of the first child, which Natural Selection, in a harsh and impassive demonstration of its single-mindedness, has made by far the toughest.

Being a left-leaning, feminist, empathic sort of person, with only mild Asperger’s syndrome, I might easily have been tempted to recommend that women in labour listen to whale music in a giant tub of yoghurt under an oak tree with their partners messily massaging the small of their back until second stage kicks in. 

Had it not been for our first childbirth.

Jenny took five days to decide to come out above rather than below the bladder. The emergency C-section under general anaesthetic has been a familiar shipwreck of the dreams of far too many couples.

At first, I used to believe that this meant the need for more intense childbirth preparations, particularly in relation to managing one’s expectations. Then a weird thing happened. I noticed that those least likely to make such preparations – teenagers from less privileged backgrounds – often had remarkably good labours. When asked in advance what their birth plan was, such a person might typically say, “Whatever …”

Eventually, I stumbled on the obvious answer: It is all about dealing with stress and anxiety. More stress: more adrenaline. More adrenaline: more pain; tighter pelvis; weaker contractions.

More chilled: more natural oxytocin; more compliant pelvis; stronger contractions. More 'whatever'. Childbirth preparation helps, but it does so especially in proportion to the amount it helps you take control, at the same time as relaxing and let it happen. 
(Easy for a man to say.)

(For a man to write, actually. Asperger’s kicking in.)

So I ended up spending a lot of time explaining to first-time mums the need to chill out at home as long as possible, (as long as all was well and the baby was moving normally). Have a bath. Have something to eat. Go for a walk. Watch an East-Enders box set. OK, perhaps not East Enders. Anyway, chill. Have the transport ready then only get in it when you reach the “Get this baby out!” stage.

It shows what an English city-dweller I am, than in all these considerations, it never struck me to doubt that the transport would always be there. Not just the car, but someone to drive it, fuel to put in it, money to pay for it, and a short road to drive it along.

This set of thoughts has been flashing through my head because of a recent email from Berega: A bus and car crash near the hospital has led to 49 admissions, many of them critical, in a hospital whose resources are already badly overstretched.

In Tanzania, there are no tarred roads in rural areas. Just dirt roads which get flooded and scarred by the ironic flashes of angry waters through this parched landscape.

In 2010, there were 1.24 million deaths on the world’s roads, most of them occurring in countries like Tanzania, where overcrowded transport, packed with the poor, the needy and the pregnant, recklessly charges towards its destination; or sometimes its destiny.

In the territory of Berega Hospital, the problem is made worse by the unaffordability of cars. Bikes and motor bikes are the only ways to make a longer journey. And they are by no means always satisfactory.

                                       

 

    

My mind goes back to two of the most disturbing memories of my time at Berega – both of them relating to transport rather than health. One was of the woman who came from a distant village on a motorbike having been in labour for five days. For the last three days, the baby’s head had been out, and the body still in. In that state she managed the unimaginable middle passenger journey to reach help. More unimaginable still was the woman who arrived too late, having bled just too much on the bumpy ride in. Her body was taken back to her village and her family, a lifeless middle passenger on a bumpy ride back.

When I went to Tanzania, I had imagined that health services were the central plank in the strategy for saving mothers’ lives. But just as the causes of death are complex, so are the solutions. Fabulous maternity services that no-one can reach, that no-one can afford, will save no-one's lives. Whatever we do, it has to involve community development. It has to address, more urgently perhaps than any health priority, those issues which prevent access to care: for instance poverty, lack of female education, and poor transport.

Whatever solutions exist must, (the WHO now tells us), be first articulated by the village women themselves, if they are to be pursued sustainably:

http://apps.who.int/iris/bitstream/10665/127939/1/9789241507271_eng.pdf?ua=1

Whatever we do, we must get out into communities and engage with pregnant women and their sisters and their carers, if we do not want them to become next year’s mortality statistics. Whatever these mums feel might be the solutions, be it to poverty or education or transport, those are the directions in which we must travel.

Whatever.

For reference: What size for Women's Groups in Rural Tanzania?

EMBRACE-Tushikamane 

'Empowering Mothers & Babies to Receive Adequate Care & Equality' - 

'We are joined in solidarity'

This is a technical note for those who might be planning on setting up women's groups in rural Tanzania, with a view to trying to reduce the dreadful maternal and neonatal mortality rates.

One of the early planning questions is exactly what size of territory a women's group should represent; what that means for the number of 'Community Facilitators', (CF); and the implications for the demographics within that small population.

Here then is some useful info based on published data, for those doing any such planning:

Tanzania has an official village and hamlet structure. 

A 'hamlet' is 100 households. A 'village' is 3-4 hamlets. (See http://en.wikipedia.org/wiki/Poverty_in_Tanzania)

This is what a hamlet looks like in rural Morogoro region: http://www.youtube.com/watch?v=cDGP2GJRWuA. 

If one women's group should could cover (say) 700 population, then in rural Tanzania this would mean:

• one hamlet per women's group may be just about perfect: it contains around 700 people, (if 7 people per household);
• this covers about 6 x 4km of territory, (pop density 31/sq km); 
• each hamlet of 700 people might have 28 births/year, (Crude birth rate 39); 
• (of which mothers at least a third should be in the group); 
• there may be 175 women of reproductive age, (WRA 47%); 
• the healthy of whom would go on to have more than six children, (fertility rate 6.3)
• With a MMR of 454 in Tanzania as a whole, and ??750 in rural areas, there would be one maternal death every 5 years for each hamlet /women's group;
• Infant MR of 51, and under-5 MR of 81 in the country as a whole, are serious under-estimates in rural areas, so of the 28 births, perhaps 2 neonates and one further under-5 will die each year per hamlet.  (see: http://www.nbs.go.tz/nbs/takwimu/references/Tanzania_in_figures2012.pdf)

With one Community Facilitator of Women's Groups covering two villages, ( = 8 hamlets & 8 Women's Groups), this would be a population of around 5,000. 

That would mean that each CF would start off with one maternal death and 20+ baby/child deaths per year on her patch - huge scope for any intervention to show benefit.