41. Expecting mothers …

When I first started going out with my lovely wife, we discovered unexpected things about each other. Once we got beyond the unbridled physical passion, (on my part anyway; hers was more an unbridled physical forbearance), we each realised that our new sweetheart had certain annoying attributes which needed fixing. As you might imagine, mine are still being fixed. Wives have an uncanny talent for fine-tuning the end-marital-product.

By contrast, I was almost completely happy with the product I was getting:    

       

   

           Mis 2015                                                  Mis 1973

… and indeed a short while into the relationship, I tore up the receipt.

There was one thing about my beautiful inamorata, however, that drove me potty: Patience.

“Patience? A worthy and desirable attribute in a person, surely?”, I hear you say.

And you would be right … up to a point.

“Up to a point?? A point where impatience is better than calm equipoise? Surely not?”,

I hear you add.

(I will be OK from here on in, by the way, if you want to take a break from interrupting people’s blogs.)

Yes, there is indeed a point where impatience is better than calm equipoise. And it is this: green traffic lights. Who in their right mind (other than my wife-to-be), slows down at green traffic lights, ‘in case they turn red’? What sort of mad sealing-of-one’s-own-fate is that? Of course they might turn red! That’s what they do! They are traffic lights, for Pity’s Sake!!! We are already being overtaken by octagenarians recovering from hip surgery, so yes, they will indeed be red by the time we get there!!! We cannot spend the rest of our lives together stopping at both red and green traffic lights!!!!

Anyway, you get the point. Miriam is a naturally patient person, and I am not, (although I am considerably better for the four decades of uxorial effort put into upgrading me).

(Before moving on, by the way, let me just point out that natural impatience is not, in itself, a vice. It has, occasionally, stood me in good stead – for instance in surgical crises, where the stop-at-green equivalent might be, “Hi everyone! How are things? And the family? Oh my! Bernie! Is that green you are wearing?! It’s funky, man!! It was great fun last Friday, wasn’t it? Do you know, sometimes we should just take deep breaths and suck in the pure joy of our friendship. But not now, because I just cut the aorta by mistake.” 

I freely admit that this is a wildly inappropriate stereotype of patient people, and that they are almost always right. And that patience even in surgery is a key attribute. I just needed to get it off my chest.)

Funnily enough, however, something within impatience does have another, positive, and somewhat more unlikely role. Unlikely, because I am referring to a role in Africa, where patience is traditionally measured on a different spectrum; (archetypally, where ‘never’ is only just above mid-point). To be impatient in an African project is to self-explode. Indeed, if you look carefully in the bush around where you intend your project to take place, you might well find the spleen of a predecessor who had a similar idea.

Why, then, am I feeling a bit sanguine at my choleric disposition? Well, it seems that when you strip away the negative aspects of impatience – the bad vibes; the intolerance; the jumping to conclusions; the making mistakes; etc – you are left with something actually pretty useful: Expectation. The expectation that, at the right time, the right thing will happen. (A bit like preparing a crab for the table: when you take off the bits that pinch you and the bits that poison you, there is something worth having inside.) (If you are fond of crab.)

This type of expectation is not vague or misty. It is an Expectation. It knows what it is after, knows it is coming, and is waiting, bright-eyed and alert, for it to arrive. It is not to be denied.

The setting up of Tushikamane took two-and-a-half years, and demanded not just patience, but a type of steadfast, quiet determination on behalf of many people, which I, for my part, was not very good at. But now, we have begun. The teams are trained; equipped; locally commissioned; accepted. They have now entered the small collections of mud-huts in distant Tunguli and Msamvu, and have begun to form women’s groups. These groups will be taken through a process whereby they explore the roots of the problems that kill them and their children. Thereafter, it will be the women themselves who lead the process of prioritizing which problems each hamlet is going to tackle.

Here is an excerpt from the February report of Wilbard Mrase, the Project Director:

“Tushikamane project is progressing well; already three women’s groups are formed at Kwiboma in Tunguli and Dibabala and Kipera in Msamvu village.

Each group has a chairperson and a secretary.

Kwiboma has 18 women in the group and the group is called Amani, (which means ‘Peace’)

Dibabala has 30 women in the group and group is called Upendo. (which means ‘Love).

Kipera has 18 women in the group, name of the group not yet given.

These three hamlets Kwiboma, Dibabala and Kipera decided/agreed to meet every Saturday at 2Pm, Sunday at 2Pm and Friday at 9Am respectively every week.

… On 27^th and 28^th January we will be in Tunguli and Msamvu in order facilitate establishment of another four women groups (two groups in each village)”

     

                    Kwiboma Group

Upendo Group

  

Kipera Group

So. It’s happening. We have women’s groups in remote villages in Tanzania; where 10% of children die and maternal death is a frequent visitor. The expecting mothers for the first time will have an empowered and legitimate voice in determining what to what to do about these tragedies.

And we also have an Expectation; an Impatience: to consign these avoidable deaths to history.

For reference: Revised guidelines for Meeting 1: the hamlet gets together to form the Tushikamane Group

MEETING1: THE HAMLET GETS TOGETHER TO FORM THE GROUP

What is the purpose of Meeting 1?

Before the Tushikamane process can begin to form groups within the hamlet, there needs to be a meeting within the hamlet of anyone who has any sort of potential involvement in the process.

However, with the leaders of the wider community having already met and given approval to the process, there is no need to repeat this high-level meeting at the hamlet.

The purpose of Meeting 1 in the hamlet will therefore be:

1.    To inform the local community about the project, and ask help and involvement, and

2.    To recruit the women who will form the core of the Tushikamane group.

Who should attend Meeting 1?

Even though the Tunguli and Msamvu Wards have given permission at high level, it is a good idea to get local leaders on board. Meeting 1 should therefore include:

•          Any existing community group networks or any NGOs or other organisations working with that hamlet

•          Traditional leaders and elected representatives in the hamlet

•          Religious leaders

•          Especially, key women in the hamlet – eg teachers, women in positions of leadership, as well as women who are natural leaders

Additionally, of course, meeting 1 needs to include all the hamlet women who will then form the Tushikamane group.

Who is in the Tushikamane Group?

The Tushikamane group begins as a ‘women’s group’ who will conduct meetings 2 to 7, in order for the women to explore the root-causes of death, and to come up with some ideas as to what to do about them.

This group will at first be almost all women, and should include:

•          Young women, mothers and pregnant women – and especially those women who come from a family that has lost women in childbirth, or suffered the death of a baby

•          Village Health Workers (even if male)

•          Traditional birth attendants

•          Traditional health practitioners (even if male)

•          But specifically it will not include the normal male opinion leaders, husbands, mababu, etc. The idea is to get women to be thinking and talking about the causes of death.

These women therefore all need to be there at the first meeting, to find out what Tushikamane is all about.

What happens at the Hamlet first meeting?

Two (African!) hours should be allowed for the first meeting of the hamlet. The meeting should be held in a centrally located venue that has ample space for all participants.

The purpose of the meeting is to get commitment, collaboration and involvement from those present to the Tushikamane process.

This needs to begin with sharing what Tushikamane is all about: to give women – especially women of child-bearing age – a voice in discussing how to reduce deaths of mothers and their babies. This will lead, eventually, to planning with the whole hamlet what things they would like to tackle, and how.

The eventual plan is to come up with really good ideas and priorities to be tackled, that will get the whole community working together to reduce these tragic deaths. They should realise that in doing so, many other benefits will begin to materialise in the community.

Topics of discussion during the meeting should include:

·         How awful it is when a mother dies

·         How the people present are an amazing resource, but need a way of working together

·         That working together will bring in help from outside agencies

·         This will especially happen if the community can show sustainable progress, and can show that their plans are working to reduce death of mothers and babies.

·         Tushikamane meetings will not be a huge demand on their time.

Hamlet first meeting agenda

The recommended agenda is to conduct the meeting as follows:

1.    Welcome, introductions, and objectives of the meeting should be set out by the Project Supervisor, Alex Gongwe.

2.    There will be only one Project Facilitator present – the one who will be working with that hamlet.

3.    The Project Facilitator, with help from Alex, will then explain a rough outline of the way Tushikamane works:

Phase 1: Identifying problems together	Five meetings	2 – 6 months
Phase 2: Identifying solutions together	Three meetings	2 – 3 months
Phase 3: Implementing solutions together	Three meetings	6 - 12 months
Phase 4: Evaluating together	Three meetings	2 - 3 months
Total		12    – 24 months

4.    At some point, Alex should clarify in a bit more detail the types of practical solutions that Tushikamane groups may want to implement; of the type he has seen happen in Malawi: eg Transport; clean delivery kits; income generation; TBA training; improving health facilities; vegetable gardens; malaria prevention; better sanitation and or water; etc. (See annexe 1)

5.    Questions, comments and ideas from the audience. Give plenty of time for questions and answers. Encourage people to come up with ideas about how it could bring about good things – and about what part local people could play in making it happen.

6.    Finally, it would be good if a group of 2 or 3 hamlet people formed a committee to help the Facilitator run the Tushikamane process – eg help her set up meetings, help remind people to come, give her advice and support, etc.

7.    The Facilitator should make a register of all attendees, and take minutes of what was said. These need to be properly written up. An electronic summary needs to be later on agreed between the Facilitator and Alex, and this summary is then emailled to the Project Lead, Wilbard Mrase. (see Annexe 2)

8.    Closing remarks by Alex Gongwe.

Annexe 1

Establishing what Tushikamane will  - and will not - provide

Before the meeting finishes, and the Tushikamane process gets formally under way, there needs to be complete clarity in the community as to what will, and will not, be provided to the hamlet by Tushikamane:

What will be provided to each hamlet:

A trained Facilitator will form a Tushikamane Group and will lead meetings.

A Supervisor will help the Facilitator achieve success with the Group.

Once the process has reached the point that the Hamlet has examined the root-causes of death of mothers and babies, and has prioritised what it wants to do about them, Tushikamane will try to help provide the hamlet with links to those who can help – for instance links to other hamlets tackling the same problem; or to local organisations or initiatives which might be able to help; or to charities and NGOs who are looking to support the kind of thing being planned.

Examples

For example, the hamlet might prioritise the development of transport solutions to help get sick pregnant women to hospital. Perhaps other hamlets locally will have prioritised the same thing. Tushikamane might be able to put the communities in touch with a charity willing to provide a motorbike ambulance, once the charity is sure that the systems for maintenance, driving, etc are all in place.

The Tushikamane groups in the hamlets would then take responsibility for making sure that such systems are implemented.

Other examples might include:

·         Skills development – eg Setting up a programme of ongoing training for Traditional Birth Attendants

·         Health Services – eg Setting up accessible services for immunisation, checking blood pressure, treating anaemia, etc; or Helping the community to embrace appropriate family planning, and to provide services

·         Agriculture and food – eg Setting up feeding schemes for weaning babies

·         Education – eg Improving maternal education about health in pregnancy

·         Environmental health and sanitation – eg all working together to improve access to clean water

What will not be provided to communities:

·         Financial support or handouts of any kind from the Tushikamane team itself

·         Incentives or ‘Asantes’

·         Things being ‘done to them’ by others without their participation. Any help which comes will begin with community self-determination, and community participation. It will not be based on what outsiders think the community might need. It will not just be ‘dumped’ onto the hamlet.

Annexe 2

Key issues for your report on Meeting 1

·         The attendance register should be summarised: how many came, how many were women, how many were pregnant?

·         How did the meeting go – any particular achievements or problems?

·         Who are the local committee / steering group?

·         What are the rules for the way the meetings will be run?

40 Annexe: Tushikamane team meet the Kilindi District Medical Officer team

KILINDI VISIT REPORT TO DISTRICT MEDICAL OFFICER  TO INTRODUCE TUSHIKAMANE PROJECT AT TUNGULI AND MSAMVU VILLAGES ON 18^TH DEC 2015

Our journey to Kilindi district medical office and district council was very successful.

We started our journey at 6:00 am and arrived at Kilindi at 10:00am, we had few minutes to pick village leaders from Tunguli.

We were warmly welcomed by Kilindi district medical officer and other three member of hospital management team (these were district hospital secretary, district coordinator of maternal and child health and one medical doctor).

The team that went to Kilindi district is as follows

1.      Rev.Canon Isaac Mgego

2.      Rev.Dr.Alex Gongwe

3.      Wilbard Mrase

4.      Tunguli ward executive officer

5.      Tunguli  Village  executive officer

6.      Chairman Msamvu village

7.      Chairman Tunguli village

8.      Ernest Bayona (Hospital driver)

We started by introducing the project and explained the detail of the project including all four phases and all 14 meetings in the project. The district team was very attentive during introducing and discussion of the Tushikamane project.

The concept of the project was highly appreciated by the district team also district acknowledged that maternal and infant mortality are still major problems in Kilindi district. The district medical officer agreed with us that using community mobilization can easily reduce  maternal and infant mortality, he also says that the deaths that are reported are only from health facility and death that occur in the community are never reported.

Despite appreciating the planned interventions of the project they had four questions, below are questions asked:

1.      How long will this project take in the community?

We answered that the life span of the project is unknown or has only when there are no maternal and neonatal problems existing in Tunguli and Msamvu.

2.      What improvements (health services improvement) are going do at Tunguli health centre especially basic and comprehensive emergency obstetric care? As part of this question of one district team member said it is very easy to sensitize people but if people go to health centre and find no quality maternal and children health services they will disappointed by our project.

This question was  answered by hospital director by saying the plan for constructing theatre at Tunguli health centre is there by involving different stakeholders including district team themselves and our friends from UK.

As part of improving health services at Tunguli health centre the hospital director asked the district medical officer to employ required number of staff in order to move concurrently with other interventions, the district medical officer agreed with this request   and they  are now in a process of preparing and signing service agreement .

3.      What are the role(s) of women’s group?

We told them that the role of women’s group in sensitize and stimulate others women of child bearing age to identify their own problems and plan solutions together under guidance of facilitators.

We also gave them a copy of Tushikamane manual for clear understanding of the project.

4.      What is referral system under the project?

The hospital director told them that the plan is to have motorcycle ambulance before establishment of Theatre at Tunguli health centre

 We had budgeted to pay an allowance of TSH 80,000 (£27) each to the 12 district management team, to secure attendance and buy-in of the project. We have decided not to incur such cost because four members of the team are now aware the project and they can clearly explain to their colleagues.

We told them that no donors are supporting Tushikamane project, thus why activities of the project are more volunteering and this will enhance issue of sustainability.

After discussion with district hospital team we went to district executive director and we were led by district medical officer.

The district executive director was very positive to the project  and insisted the Tushikamane project leaders together with village development officer to collaborate and think for income generating activities for women’s group  as part making group together without going beyond Tushikamane plans and finally wished us all best in our project .

What is next after Kilindi Trip?

The week beginning 21^st  Dec 2015  we will establish baseline survey guideline, and after full discussion and modification, we will then perform the baseline survey between 28^th Dec2015  and 4^th Jan 2016. 

Wilbard Mrase

Tushikamane Project Director

40. Thanksgiving

Thanksgiving originally began with Michaelmas, at the end of September. In fact, for the Celts, the entire year began with Michaelmas. Punctuated by the quarterly pagan festivals of yule, easter, and midsummer, the Druidic year finally wound up with a thanksgiving for the harvest. Along with thanksgiving, the end of the Celtic year was traditionally a time for the settling of debts, the renewing of employment, and, apocryphally, the sacking of the manager if they had lost to Rangers.

American Thanksgiving, then, as a celebration, had its roots in the September Celtic harvest festival. The Pilgrim survivors of the Mayflower in 1621, however, had to wait until the end of November for there to be enough provender on the table, and enough turkeys stupid enough to wonder what the business end of a blunderbuss smelt like.

Each year thereafter, the Pilgrims gave thanks.

And so it was that the custom grew up in the New World, that on a Thursday in late November, entire extended families of turkeys would gather together in WalMart, having been persuaded that they would thereby be first in line for Black Friday Christmas bargains. (Thursdays have since been generally considered by turkeys as unlucky; as have sage, cranberries, baco-foil, and ovens.)

"I will not wear my scarlet coat ..."

The reason for this educational and historically insightful introduction is that a recent Thursday was indeed, for many, Thanksgiving Day, and I was invited to my first ever Thanksgiving dinner. The setting was the Staff House at Berega Mission Hospital, in rural Morogoro, Tanzania.

http://www.youtube.com/watch?v=n84o3Mztf9o

  

 Staff House verandah

Several of the surrounding houses are home to some wonderful American ‘Hands4Africa’ volunteers, who teach at the local village school. (The selfless determination and drive of Brad Logan, Ruth Mgego, and H4A supporters, have, in five short years, developed the school exponentially. From a hut in which the legendary Mama Liz taught six sparky kids, it has become a set of inspiringly embellished classes catering for more than 130 eager and successful local village pupils. What joy to see the next generation of Tanzanians being disabused of a heritage of poverty and ignorance.)

Thanksgiving Day itself, coincidentally, was the last day of the school year, and so Teachers Lisa, Marianne, Bette and Chris were ready and eager for a night of shared festivity. Dr. Kristien, Dr. Al and his wife Engineer Emma made up the rest of the gang, along with my good self, (Loafer Lozza). The fayre was classic Berega: stone-ground bread, (ie bread made from ground stones); chopped tomato and onion with amoebic dressing; micro-omelette from local pygmy chickens; goats-nest soup; marsh cactus wedges; and of course the traditional 'brown-crunch' - a sort of vegetarian version of dung beetle.

We ate. We drank a little beer. We put the world to rights. We killed a few cockroaches. (Although somewhat pointlessly. Others sprang into the breach to take their place, climbing over injured comrades to sell their lives dearly.) And then we sang. Lisa has a heavenly voice somewhere between Joni Mitchell and Lady Gaga. She said that my voice was somewhere between Elvis and Pavarotti, but it turns out she meant geographically, reminding her of a traumatic bird-watching experience in The Azores.

One telling moment was when each of us had to say something we were especially grateful for in the last year. Having had a new granddaughter in May, my special thanks was for offspring. Thinking back, it strikes me now that the thanksgiving contribution of each of the others was just a sentence or two, so perhaps I shouldn't have shown quite so many photos of my youngest granddaughter, Layla Miriam.

("This is Layla lying on a mat. Here she is lying on a different mat. This one is of her looking quizzical at the mat change. She's very intelligent, you know. She can tell the difference between presbyopia and hyperopia, often taking the glasses from my face when I'm not reading. Here's another one of her not on any mat at all ... " etc)

 Layla Miriam not on a mat

At about midnight, Kristien went off to check the hospital, and so ended a lovely first Thanksgiving. A quick cull of mini-predators, a sluice of the torso with a moist banana leaf, and I was deeply asleep.

Somewhere before dawn I was woken by what at first seemed like singing, coming from the distance and getting louder and louder. As it passed nearer the house I could hear that it was wailing: a heart-rending, plaintive, inconsolable wailing, that I knew meant death. I got up, but what could I do, so I went back to a troubled sleep.

Next morning, Kristien was up before seven, despite her nocturnal tribulations. She told me that when she arrived at the hospital, she found them unsuccessfully trying to resuscitate a four-year-old boy, who was dying of cholera. His brother was also badly dehydrated, and the father less so, but both still very ill, pooing and vomiting uncontrollably. The wailing, then, was for the death of the young lad? No, said Kristien, it was for a pregnant woman at full term, who died at the hospital gates from a ruptured uterus. Maybe fear of the rain kept her too long at home, or maybe it was fear of upsetting the traditional birth attendant, or fear of the cost of hospital, or fear of dying there. Most likely a combination of fears, some well-founded.

So a death of a mother, and of her baby, and a further child death, all in a day? Not only, said Kristien. Yet another baby died in the premature baby room, and yet another again was on the brink when she went to bed.

I said poignant goodbyes and set off for Dar Es Salaam without knowing what happened to the father and son. This is a video of what the terrain looked like along the way, and, between poverty and lack of infrastructure, you can see why death is so desperately common:

https://youtu.be/aJuhyV2oOBg

Kristien will have been in the hospital for the best part of a year when she leaves before Christmas: home to Belgium, and family, and friends, and winter, and jumpers, and comfort, and showers, and toilets, and food; and chocolate; and sprouts; and safe refuge from cockroaches, cholera, and unending tragedy. An amazing woman. Interestingly, when I asked her how she had coped with so much, it was thanksgiving in a way that kept her sanity. Ranting about the fickleness of Fate leads to anger; and anger erodes. It's knowing that sometimes you make a difference that keeps you going. Sometimes, thankfully; but only sometimes.

But in my Thanksgiving week at Berega, there was indeed something important to be thankful for. The EMBRACE / Tushikamane project was officially launched, and the Tushikamane team took the helm.

 Team Tushikamane 

Chairman is Rev. Isaac Mgego, who is also Director of the hospital. He is a man of God, and a man of the people, having been the first person in his village to go beyond primary education. He paid for it himself by making and selling charcoal, and eventually finished his education with an MBA.  His will visit the project villages weekly, with the Project Director, Wilbard Mrase. His role will be to help solve high-level issues, and to make bridges to other initiatives and organisations working to the same end.

Wilbard Mrase is the powerhouse who will teach, drive, direct, fix, make things happen - and report back monthly the progress and problems. His day job is to lead the Berega School of Nursing, and his passion is reduction of maternal death in the community.

Rev. Dr. Alex Gongwe is a charismatic medic living within and serving the Tunguli and Msamvu communities. Here he is, role-playing with Facilitators Simon and Esther, showing how not to persuade villagers to improve their lot:

https://youtu.be/tHWwrpdVehk

He is the Project Supervisor, and is the direct boss of the front-line workers. His role is to equip them with the skills, materials and understanding they will need for each micro-stage of the journey; to listen; to trouble-shoot; to fix things; to expect appropriate activity; and to help turn activity into achievement ... and measurement of achievement. He will also look for synergies and harmonies, not just between the Facilitators, but also between Tushikamane and other village-level initiatives.

The Facilitators are Esther Paul, Noadia Mganga, and her assistant, Simon Jackson. They will be the ones going into the hamlets, meeting the young women, the pregnant women, the mothers, and the female influencers. They will begin a chain of events whereby they listen to the women’s voice, and they muster their collective yearning for things to be different. The vital ingredient of the process is that the village women themselves probe what might be the roots of the staggering death rates of mothers and children. The village women themselves then prioritise which three or four of these they would like, with the help of the men, to tackle. The Tushikamane team will help them align to any useful support, initiatives and organisations.

But even with a good idea such as community-participation-with-the-aim-of-reducing-death, you can’t just pitch up and get on with it. In Africa especially, you need buy-in at every level, and you need the imprimatur of the powers-that-be. And so it was that Wilbard and Isaac called an introductory meeting of the entire superstructure of the Tunguli and Msamvu villages.

Quite incredibly, no fewer than thirty-seven head-men, leading women, teachers, elders, priests, imams, health workers, NGO workers, and the like, gathered for what was in effect the local launch of Tushikamane. Oh yes, and me. A three-hour discussion in Swahili ensued, some of which I did not follow. (Specifically, the bit after "Good morning Ladies and Gentlemen ...") It worked. The response of the (mainly male) community leaders was not just overwhelming support, (deeply encouraging though that was), it was that they really understood where we were coming from. One by one, they got up to say so. Change had to come from within. Sustainable change to maternal mortality had to start with mothers.

They got it.

 Tunguli & Msamvu village leaders with the Tushikamane team 

Tanzania & Tunguli

As I began to write this from a comfortable hotel in Dar Es Salaam, the week in Berega seemed almost a little unreal. Just 350 kilometers away, death is a frequent visitor to every village, and yet here, I had just had a door-knock from the hotel anti-pest service, offering to spray my curtains with anti-mosquito. (I asked if they could spray the door with anti-knock, but they ran out.) Soon, I would be at home with a glass of vino in one hand, and metaphor in the other, putting the final touches to a blog, from the comfort of Earlsdon.

Like the Pilgrim Fathers, I feel that I have so much to be thankful for. Maybe this Christmas, as you peel the baco-foil from the unlucky bird, you might want to give a thankful thought for how far much of the world has come since those pioneers … and a wistful one for how far much of it still has to go.

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