28. Niall, Zayn, Liam, Harry and Louis

Where is your life going?

Three years ago, the answer to this for Niall, Zayn, Liam, Harry and Louis seemed to be: “Nowhere”. The singers were headed out of the glamour of the ‘X-Factor’ talent show, and back into the anonymous twilight of open mike nights and high-rise hair competitions.

But then they were thrown a life-line: They could re-enter the X-Factor: but only if they joined together to become a Boy Band, and only if they called it ‘One Direction’. They did; and they did. And they did very well. In fact, if you are a pre-pubescent girl, the chances are that you sip your cocoa from a One Direction mug; that you seek comfort in their music when your dad is being SO unfair; and that your sleep-over is under the watchful vigilance of five guardian-angels smiling down from the wall.

Fairy-tale success. But then Stephen Covey could have taught Simon Cowell a thing or two about ‘One Direction’. The ‘One Direction’ concept is one of the ‘Seven Habits of Highly Effective People’. Stephen Covey’s seminal book has sold 15 million copies in more tongues than there are mouths, and it articulates the secrets of success of human endeavour.

His First of the seven Habits is to suggest that the readers gets off their butts and get moving. Immediately thereafter, Stephen adds the Second Habit: that they should know where they are going. One Direction. The rest, by comparison, is easy.

(By the way, even if Stephen Covey thought of the idea of ‘One Direction’ first, and so maybe had a right to that poster wall-space, I have to agree with Simon that Niall and the lads have greater merchandising potential. Stephen may be a super-legend, but to a teenage girl weeping into her cocoa, he looks like everyone’s dad.)

“Hi girls!! Don’t be sad!!! Let’s party!!!”

“You are going to be an accountant, and that’s that”. “You’ll understand one day, Mariah”.

Anyway, the point is this: five directions, five failures. One Direction; one Massive Success.

The reason for stepping out onto this philosophical path, in the reawakening of the Lost Blog, is that last week I had to explain EMBRACE-Tushikamane to a willing but perspicacious male-only audience*:

·         that we were intending to tackle the awful death rates of mothers and children in rural Tanzania;

·         that the roots were deep and complex;

·         that shipping in foreign aid to prop up the situation, only seemed to produce a temporary benefit; and

·         that the evidence was emerging that setting up women’s groups, and allowing them to set the agenda, seemed to produce a lasting benefit, and an ever up-surging thirst for progress.

At first, I had no problem with this. Empowerment of women in the world would redirect our attention from war and waste to the things that matter. That will save lives.

But then a thought hit me: Men also want water. And sanitation. And a clinic. And transport. And healthy children. Am I saying that when men express the need for a well, or a toilet, or an ambulance, that things go wrong? That it needs women to spell it out before will work?

Nevertheless, it is so clear that empowerment of women through women’s groups is the way ahead, that the World Health Organisation has now issued official guidance on the importance of this methodology in reducing death in rural Africa:

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

So we have a puzzle: why are women’s voices more magical, more effective? What is it about enlivening the animation of an uneducated rural African mum, that lights the fuse of an explosion of development?

I had to think long and hard. I have known many rural African women, but as an urban European male, I think differently. What’s wrong with my way of thinking? What’s wrong with men? (My wife, looking over my shoulder, says “How much time have you got?”)

And then it hit me. In sub-Saharan African villages, men often represent Authority and Institution. Tradition. The way things are. And in these breathless days of the twenty-first century, Institutions are in many cases crumbling, precisely because of being what they are – instead of what they might be.

Institutions are in danger of not getting those first two of Stephen Covey’s most important prompts: Get moving. And know where you are going. Together, on the same journey.

Women talk. They listen to other women talking. (My wife, looking over my shoulder, says “It’s not that hard.”) Rural Tanzanian women fetch the water. They find something to cook. They work. They raise their children and look after them when they are sick. Too often, they die young. They want a better world, and they are willing to work hard, for years, to reach that goal.

Given just a hint of a chance, they will have One Direction.

When they start the journey, we will be there to help.

(By the way, one generous man at this talk, inspired by the empowerment of women, gave £1,000 to help with transport solutions, when the women articulate this need. Thank you very much, A. That is lives saved.)

For reference: EMBRACE Tushikmanane - where we are

With several weddings and a 60th birthday, I apologise to blog-readers for the long gap.

I am now back in the saddle, and we begin with a poisiton statement on 'EMBRACE-Tushikamane' - the project which we hope will lead to sustainable development to save many lives in rural Tanzania.

'EMBRACE-Tushikamane’ at August 2014

EMBRACE = Empowering Mothers & Babies to Receive Adequate Care & Equality

Tushikamane = We join together in solidarity

We would eventually like to set up women's groups throughout a 7,000 sq km area of rural Tanzania - the area served by Berega Mission Hospital. 

The purpose of the women's groups is to discuss the roots of the daily problems they face, in particular those which cause death in childbirth, or death of children.

Of course we already know that the roots of these problems include malnutrition, malaria, poor education, lack of transport, diarrhoeal disease, lack of health facilities, etc etc, but we need the women themselves to articulate this. This seems to be a vital preliminary to making the solutions sustainable: unless the community has self-direction, outside aid often does not lead to long-term progress.

We have chosen an area to begin in, and have community buy-in. (Tunguli - chosen because Berega already runs a rudimentary health centre, inpatient and maternity service there.) The area is inaccessible in rainy periods, and perhaps as many as 20,000 people live in the wider community served by the Health Centre.

Resources and manpower already available

The hospital director and his deputy are 100% behind the project, and have excellent skills in driving change and making things happen.

We have a Project Leader and her deputy ready to go. One is the previous matron of the hospital, and the other a bright, younger nurse. They are waiting to be told what to do and how to do it.

We have money for a year's salary and expenses, plus some reserves, and I am sure could get more when needed. There is constantly available accommodation if we deem part of the solution to be sending out volunteers. There is transport available if we pay for it. We have mapped the territory in detail.

All the charities working in this territory are fully on board and excited about what we are doing: Hands4Africa; BREAD; Mission Morogoro; and the Diocese of Worcester. Every year, representatives from these charities visits. The Director of H4A sometimes visits several times, to manage the projects they have set up - two plantations; a school; various other buildings; etc.

Ammalife houses the project and the funds. Their founder, Prof. Arri Coomarasamy, regularly goes to Tanzania for various academic collaborations.

Measurement

We intend to measure outcomes in several ways - firstly by things that actually happen arising from women's group discussions - eg new transport, school room, immunisation system, etc etc.

Secondly, we have completed a mapping exercise so that we have each hamlet name mapped out. The hospital can therefore record where deaths and other significant events are coming from, and we can therefore monitor, with time, any change in health demographics.

Thirdly, an important academic need is the observation of the process: what helps and what hinders? Given that women’s groups are the internationally favoured approach for tackling maternal and child death in rural Africa, we are well placed to inform the academic community as to practical roll-out of the guidance.

Immediate needs for EMBRACE Tushikamane

1.     How do we get someone to train and supervise the Project leaders? They, when trained and ready, will in their turn need to train and supervise the Community Facilitators who will lead the development of women’s groups on the ground.

We are looking for help for this with high level experts who themselves have informed the recent WHO guidance on this approach:

http://www.who.int/maternal_child_adolescent/documents/community-mobilization-maternal-newborn/en/

2.     To whom will they report? We will need to form an international working group, with strong local representation, but with expertise and support from key individuals and organisations outside of Tanzania. This might well need to involve an academic institution running a formal project and evaluation.

3.     Nevertheless, the reality is that the project will be driven from the UK. How can we know that things are happening as they should? How can we project-manage from 5000 miles away?

4.     How do we link to all those who might be doing similar work in Tanzania - especially those with funds?

5.     Through all of this we will need good communications, and good updates using social media. This is no small undertaking.

Longer-term needs

1.     How do we capture the issues being articulated?

2.     How do we prioritise them? I guess by the degree to which we think they might have a long-term effect on the dreadful mother and child mortality rates.

3.     How do we ensure that the intention to put in a solution gets turned into reality.

4.     How do we build enterprises into the solutions, such that economic growth occurs alongside other improvements?

5.     How do we ensure that good data gets collected in the hospital? This needs special attention. The hospital does have reasonable data collection at the moment. The majority of admissions, discharges, deaths and outcomes are recorded with fidelity in the ward and admission books.

However, for the project we would want data to be as accurate as possible. This might well need the sevices of a volunteer to set up a parallel data collection system for the purposes of the project, to include: deliveries; survival; complications; village and hamlet of origin; and attendance at women’s groups.

6.     Whereas the £ goes a long way in rural Tanzania, nevertheless ongoing funding will be needed, and this is likely to involve the troublesome process of grant applications.

Special post!: The privilege of Joy!

This is why I have been out of touch!
It was a very beautiful day!
Blogging will recommence soon!

27. Bah! Bar black sheep?

In May, in Berega’s territory, four more mothers and dozens of children will have died needlessly of preventable causes, whilst from 5000 miles away, we try to help to make a difference. If we give up, the weary fall-back position is that neither culture will mind much; and, historically at least, neither will do much. Why have cultures had such a tendency to let things be? Why is inertia such a powerful force, when it doesn’t even exist?

Why do some cultures tolerate inappropriate death, inefficiency and corruption?

In the UK, we have an expression ‘the black sheep of the family’. It refers to people whose waywardness or disreputability makes their elderly aunts rarely talk to them. 

Black sheep are barred from the cosiness of social acceptability. Is it not strange, though, that black sheep are not prized? They are unusual and striking animals – precious offspring arising from a rare genetic event. And yet shepherds, far from valuing these future stain-proof garments, traditionally regard them as a bad omen.

The reality is that we humans have a tendency – like sheep – to do what those around us are doing; and if that means being woolly, saying “Baa”, and looking for grass in a blizzard on a hillside, then that’s what most of us will do. We learn to tolerate what should really be intolerable, and to be blind to what is plainly visible. Even when it might be for our own good to challenge the status quo, an invisible force shuts our mouths and stills our passions. We have, it seems, a deep-felt and powerful need to conform to societal norms, irrespective of the advantages of sometimes breaking the mould. (Breaking the mould can indeed be good. Einstein, for instance, was an off-the-wall genius who profoundly influenced the sum of human knowledge. And yet, in an irony of relativity, he was shunned by his elderly aunts.)

On the other hand, it is true of course that in many cases this communal disdain for those who do it differently is well-founded. Society often stands for what is right and wholesome, and waywardness can mean social irresponsibility – a failure to put the community’s needs before one’s own. In such situations, being wayward will seem to most group members not just inappropriate, but actually immoral. In this way, different versions of morality grow up, fed by a bespoke mixture of tolerance, intolerance and inertia.

My point, however, is that society sometimes gets it wrong. It tolerates what should not be tolerated, and those who stand out from the herd are wrongly regarded as black sheep, even though their take may be the right one. In the Cities of the Plain in the days of Lot and Abraham, those who welcomed visitors with fruit scones, a nice cup of tea, and Gomorrah merchandising, were in the small minority. And yet history now unequivocally plumps for their approach as being more conducive to a healthy tourist industry. Sometimes unhelpful or unsavoury codes of behaviour creep into a culture, and, without even realising that not everybody invades-others-countries-in-order-to-manipulate-world-power, suddenly it is a matter of popular pride to do so. We knuckle under, and find ourselves doing what, in another epoch, or other corner of the world, might be considered ill-mannered at best, or positively immoral at worst. The way-it-is determines the way-it-should-be. 

(In middle-class English households like mine, for instance, it is a brave and aberrant husband who stands up against the tyranny of having to make conversation instead of doing important stuff.)

The end result of this natural phenomenon is that polar opposite cultures can emerge, where what is anathema in one society is perfectly acceptable in another, and vice versa. When Victorian missionaries’ wives first went to Africa, some were more affronted by the bare breasts than by the paganism. In a similar vein, in our culture now, eating meat is perfectly acceptable. But what if a hippy/New Age culture were isolated from the modern world for a couple of generations:

“Hi Meadow-Lark. Have you seen Gaia anywhere?”

“Yes, Buddica. I think she’s in the cow-home.”
(Buddica goes to cow home and finds Gaia.)

“Gaia! What in Ashtanga’s Name are you doing?!”

“Oh, hi mum. I’m just cutting Bessie’s throat. I fancied sneaking some first-class protein into our nut roast.
We may be short of yoghurt for a while.”

To us in the North-West Quadrisphere, the same outrage is provoked by the inefficiency, inertia and corruption we find in the cultures of far too many low-income countries. This week, I learned that the Tanzanian Government agency responsible for paying for certain of Berega’s staff and services, have once again failed to come up with the cash. At the same time, the national power grid engineers visited to link up all the staff houses to the grid, but seemed to get equal job satisfaction from not connecting all the staff houses to the grid.

We cannot be too hasty, however, in judging the unacceptable face of an alien culture, for fear that the alien culture might point out our own more dubious excesses. What’s more, maybe if we only earned $2/day, out of which we had to bribe people to pay for basic needs, we might not feel so self-assured about the immorality of trousering the odd back-hander.

I cannot help feeling, however, an overwhelming and determined passion that Tanzania and indeed the world might be rid of such nonsense. This mouldy infestation of our planet needs many more mould-breakers: more like Einstein, some non-talkative husbands, and the nicer sort of black sheep.

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?"