13. Ammalife, hats and wandering nibs

13. Ammalife, hats and wandering nibs

20th October 2013

My blog style to date has been to start on a thematic journey, meander seemingly unhingedly, but then, with an attempt at an elegant literary double backflip with pike, deftly to return to base camp at the end. This time, however, I do not think I have managed it.

This fortnight’s blog turns out to be more of an A to B journey, of the sort that husbands make.

(I say this fully aware of the dangers of gender stereotyping, and I would be more than happy to accept into the category of A-to-B-journeying-husbands, anyone of whatever chromosomal make-up, as long as they exhibit the trait. The husbandly trait is this: Not only do they know the shortest way to the supermarket, avoiding traffic lights, pedestrian crossings and roundabouts, but they know it in metres, in minutes, and in points of the compass, and would disembowel themselves rather than look it up on GPS. On tougher journeys, they actually relish the challenge of getting there just as quickly, despite it being school-drop-off time in the rush hour on the South Circular, with the home team playing a morning fixture, on the day that the National Union of Lumberjacks had injudiciously planned their traditional annual parade in memory of the Great Fire of London, at the same time and place that Greenpeace were lobbying Parliament on the deforestation of the inner cities. Furthermore, if achieving this on-time arrival involved off-road segments, river crossings, the Spanish Steps, or squeezing through a little-known defect in the wire fencing around a disused aerodrome, then so much the better. If this is you, and if you have been known to cut off all communication with your spouse for a week because s/he went through an unnecessary traffic light on the way home, then you are, of whatever gender, a husband.)

One of the main reasons for this husbandly directness is that I want to leap straight in and tell you about Ammalife, (http://www.ammalife.org/), who have adopted under their wing the Berega plans for saving the lives of mothers and children in the remote area of Mnafu. (See separate post for the most recent summary). Ammalife, whose purpose is to make a difference to mothers throughout the world, is a rising star amongst such charities. Their founder trustee, Prof. Arri Coomarasamy, is one of the top researchers in International Womens’ Health, and has collaborations in many countries, including Tanzania.

(I remember him, though, when he was a doe-eyed youth. He was my houseman/junior intern many moons ago, and perhaps he is the man he is today because I did not stint in using on him the well-honed tools of the day for nurturing intellectual growth: humiliation; bombastic overbearing outbursts; and insistence on the punctilious use of outmoded and sometimes dangerous therapies. (“Coomarasamy! Why did you not lance these leeches before mixing them into the linseed-and-sparrow-liver poultice?” “I am truly sorry Sir, but it seemed as if her piles were already improving with the honey-and-hedgehog-skin gamgee.”)

Anyway, Ammalife gets things done. They make a difference, and what’s more, they put considerable effort, at no expense to the charity, in finding out what it is that does make a difference. (With their high-profile partners, they apply for grants from international organisations to run large and well-constructed studies in under-resourced settings in many Asian and African countries, their most recent one published in the Lancet). Their interventions are often simple things. In a remote part of Pakistan, for instance, they have issued pregnant women who come to antenatal clinic with a taxi voucher. When the woman goes into labour, the voucher is presented, and, when time might truly mean life or death, none of it is not lost trying to find transport; nor money for transport. The cost to Ammalife is in pennies, and the saving is in lives. It is not surprising then, that Arri Coomarasamy representing Ammalife, has been asked to lead on one of the UK’s main charity collaborations, to advise on sound intervention in maternal & child health.

There is a reason I am bigging up Ammalife, and it is this. It is much more than a shot in the arm to have had the health care aspects of the Berega /Mnafu project housed within their organisation. They are not just being nice – they like what we are doing. They think it hits the spot. What is more, I will be reporting to them twice a year, and drawing on their wisdom and, hopefully, critical friendship.

So look out on the Ammalife site for a page on our plans to make a difference in remote Tanzania. (And check out the ‘my-donate’ link which you will pointed to.)

Talking of making a difference, I have to share with you this photo:

This was knitted by the worthy women of Guildford, UK. (The hat, not the baby). When Dr. Blanché Oguti visited Berega this year, she was shocked to discover that vulnerable new-born babies cannot be adequately resuscitated if they are cold. Death and brain damage from this ironic cause in a tropical country are all too common, where newborn clothing is wet and thin. So when Blanché  returned to the UK, she talked to her mentor, Dr. Debbie Donovan. A few months later, the charity KOFIA has already knitted 1000 hats, and the picture you see is of the first ever use. The baby will keep the hat, and perhaps, one day, these Kofias might be the hall mark of a looked-after childbirth – one where the woman and her baby have been cared for in the right place at the right time, by those who know what they are doing. Those hats, back in the village, will send a deeply poignant message, from the privileged to the grateful.

I have much more to say, but will save myself until next time, when all the meetings and first phase groundwork of the plans will be complete. In particular, the charities Hands4Africa and BREAD are vital. Their frequent visits to Berega, to trouble-shoot and to develop, have had huge and progressive impact over the years: on primary schooling/education; the establishment of a nursing school; helping the hospital do its job; helping the community with transport, buildings and agronomy; and more. When we are all completely clear as to who is doing what, where, and when, we will then be ready to sign off a collaborative plan for stepping boldly into Mnafu, to begin walking with them on their journey into the twenty-first century. Each step must be solid, and each step will take us further from the numb toughness of the past. It’s really happening.

Well, I have used my time and word count, and seem to have taken you from Ammalife to BREAD, (via to KOFIA & H4A), in a fairly logical sequence. A to B, like a husband. I feel a little awkward about this, especially towards those who might have expected something a little more James-Joycey. Indeed it was in deference to such fans of the wandering nib, that my blog style to date has been to start on a thematic journey, meander seemingly unhingedly, but then, with an attempt at an elegant literary double backflip with pike, deftly to return to base camp at the end. This time, however, I do not think I have managed it.

For reference: ‘EMBRACE Mnafu’ Empowering Mothers & Babies to Receive Adequate Care & Equality

‘EMBRACE Mnafu’

Empowering Mothers & Babies to Receive Adequate Care & Equality

Community development plan for Tunguli & Mnafu

With emphasis on the care of mothers and babies

The Problem

Berega Hospital serves a vast and inaccessible territory of rural Tanzania with a population of 217,000. There are 8,500 births/year, of which only 1000 occur in a health facility. Nearly 1 in 100 women die in each childbirth, and up to 10% of children do not reach their fifth birthday.

The Vision

The vision is for trained Community Health Workers (CHWs) to reach out, initially to the isolated communities of Tunguli and Mnafu, working with the Traditional Birth Attendants, (TBAs), Village health Workers (VHWs) and village leaders, to develop a systems for managing  childbirth, family planning, immunisation, child nutrition, and chronic conditions (eg malaria, anaemia, diarrhoea, TB, infestations, & HIV). CHWs will also help improve collection of information – eg demography, birth rate, etc.

Partnership

This project would a partnership between the hospital, and the charities Ammalife, Hands4Africa, BREAD, Mission Morogoro, and KOFIA.

Phase 1: Solid Base

Trained CHWs will engage with community leaders, VHWs, TBAs, and mothers, to examine their problems, ideas, potential solutions, and priorities in relation to pregnancy and childbirth; nutrition; family planning; immunisation; and chronic disease.

Meanwhile, the charity Hands4Africa will be enhancing transport, agriculture, and the building of a health / community facility.

At the same time, the hospital will be working to implement a new Charter of Standards, to prepare it for the future influx of patients.

Phase 2: Making a difference

CHWs will work with TBAs on safe childbirth solutions, bringing selected women into Berega for birth. Thereafter, the CHWs would try to enhance breast feeding, family planning, immunisation, growth charting, under-5s nutrition, and prevention and treatment of diarrhoea, malaria, worms, and other chronic conditions. This would be centred at a purpose-built health and community facility.

Phase 3: Expanding capacity

Berega will expand its School of Nursing to train both front-line ‘medical’ staff, (‘Clinical Officers’) and nurses/midwives. COs can deal with childbirth, family planning, and treatment of disease.

Phase 4 – long term

The long-term vision is to learn transferrable lessons, whilst creating an economically viable community, with good health and educational facilities, and a lattice-work of COs, CHWs, VHWs and TBAs working within a well-oiled mechanism for early transport of the needy to high-tech facilities at Berega Hospital.

References

1http://data.worldbank.org/indicator/SH.STA.MMRT/countries

http://data.worldbank.org/indicator/SH.DYN.MOR
   http://www.nbs.go.tz/takwimu/references/Tanzania_in_figures2012.pdf
http://en.wikipedia.org/wiki/List_of_countries_by_percentage_of_population_living_in_poverty

12. Allegri miserere

12. Allegri Miserere
6th October 2013

What is 31 minus 13? Answer: The Sixteen.

We went to see them in Coventry Cathedral on Wednesday. There are thirty-one in the squad for each away fixture, but they select just sixteen - then throw in two extra sopranos to balance out the second basses, whose voices are richer and deeper than a sub-terranean Lindt 85% chocolate lake. That leaves thirteen on the bench, and eighteen on the pitch. Yet they call themselves The Sixteen. As there was no ref, they got away with it, and at 7.30 on the dot, they kicked off.

Unlike Sir Alex Ferguson, who seems to need the help of chewing what appears to be a squash ball in order for his players to obey his passionate gesticulations, (although I have to admit a grudging admiration for anyone who can, with a single get-those-chickens-off-the-road gesture, manage to tell the forwards to move ahead, and yet the goalie to stay where he is); anyway, unlike him, the conductor of The Sixteen, Harry Christophers, simply walked up to the hallowed Cathedral rostrum, neatly stuck his Wrigley's spearmint between the Bishop's and the Archdeacon's, and began waving.

I said that there were eighteen on the pitch, but 'on the pitch' does not begin to describe their precision, beauty and passion. I have been listening to (and singing) choral music since the 1960s, (with breaks for eating sausages and delivering babies), and this was quite simply the best.

The starter was Palestrina, which at first sounded no more than beautiful. Then, walking up the aisles like mediaeval monks, and filling the vast cathedral with their dark, rich sound, echoing from nave, nook and niche, came what you suddenly realised were the missing men; chanting a deep, yearning, haunting, mediaeval plainsong. The deepest, yearning-est, haunting-est, mediaeval-est ever heard.   I felt all the awe of a feudal serf walking past York Minster at vespers on a soggy Martinmas Eve. It was all I could do not to die of pleasure and /or bubonic plague on the spot. The fog-horn, mastodon low of the monks interlaced with the sparkling harmonies of the main group, like seams of praline in diamond, (which, for the purists, cannot be a mixed metaphor, as it is a simile). You get the idea, anyway, that their singing was indescribably beautiful. But the best was yet to come.

The second piece was Allegri's Miserere. If you have never heard it, listen to it now - it is, (or was, as I thought then), the most transcendently blissful piece of music ever written. So beautiful was it deemed in the past, that it was kept secret by the Vatican choir, and only sung once a year in the Sistine Chapel. Then Mozart heard it, wrote it down, and thereafter the souls of we ordinary citizens could immerse ourselves in it. The Sixteen's version, moving from the simplicity of the authentic article, to the modern embellished version, was indescribably sublime, but one feature in particular I wanted to mention.

When soldiers march across a bridge, they have to break the regular stomp-stomp of their relentlessly in-time bootbeats, or else the bridge might begin to resonate at that frequency. Were it to do so, the continued stomping would feed an amplifying effect, and within a minute the whole bridge could be undulating wildly - before spectacularly bursting. If you are a squaddie on leave and want to try this, but are separated from your fellow stompers, the same effect can be achieved by moving a wet finger lightly round a crystal wine glass at a constant speed. What should be a tiny noise self-amplifies, until it is an all-pervading note, and finally the wine glass shatters in joy. Amplification of human voices, to make a sound which gradually expands until it fills and vibrates the building, can only be achieved if every one of the voices is perfectly blended with the next; every mouth-shape the same; every vocal nuance mastered to the same high degree; and every pitch perfect.  I have been in the same Cathedral when five hundred voices did not make as much sound as those eighteen were capable of on Wednesday night. The magic was that they could expand from a whisper to a Cathedral-throbbing thrill in a heartbeat.

"Why", I hear you say, "is he drifting off on this musical odyssey?" "Aha!" I hear you answer yourself, oblivious to the seriousness of the potential psychiatric diagnoses typified by talking to yourself through someone else's blog, "He is going to draw parallels between The Sixteen, and saving mothers and babies in rural Tanzania." Perhaps you are imaging that I would pick up on the idea that plainsong is all very beautiful, but that when it creatively harmonises with the efforts of others it fulfils itself. Or maybe you think I might point to the self-amplification that occurs when harmony is perfect, whence seemingly impossible effects can be achieved. Even the old structures can come tumbling down, under the persistent vibrancy of simple, resonant harmony, you may be thinking I would note.

Certainly you would have a good point.  Development in rural Tanzania is an echoing, clashing, plaintive emptiness, ready and waiting to be filled with the music of harmonised effort.  Aligning the efforts of  Berega Hospital, the Diocese of Morogoro, the Tanzanian Health Agencies, BREAD, Hands4Africa, Ammalife, Mission Morogoro, Kofia, the Diocese of Worcester, and various universities, institutes, Quangos, and NGOs, will be worth all the effort put in. Three key meetings are approaching, and a fair amount of email traffic. By Christmas, we will all be on the same sheet.

However, if you were expecting that I was going to be so predictable as to make such comparisons, you underestimate me.  The actual story I was going to tell was this: Allegri Miserere was not the highlight of the show. After four centuries of prime time on Classic FM, move over Gregorio, and enter James Macmillan.

I had never been much of a fan of modern music. My unacceptably uncultured philosophy had been that if you wanted  to drop a piano from a tall building onto a barrel-organ player and his monkey; or if you wanted to put a tom-cat that keeps you awake at night in a food-blender with a duck-lure and some castanets; then by all means go ahead. But don't call it music.  By my simplistic and uneducated take, if it sounded like you had made the wrong note, then the reason was likely to have been that you had made the wrong note. I knew that many modern composers were geniuses. I knew that they could have written like Tallis, but chose not to.

Benjamin Britten, for instance, was perhaps the archetypal twentieth century genius. His tougher works, however, (unless you sang them as he planned, and that is quite an unlikely 'unless'), could have a tendency to sound like emptying a recycling bin onto the National Youth Orchestra when they were warming up. When I was in the Liverpool Philharmonic choir, thirty-five years ago, we once sang Britten's War Requiem and a modern Russian piece 'Poem to October', on the same programme. We had no time to rehearse both well, so the conductor, (looking at me, I think), told us: "Look!! I don't mind if you sing the wrong notes, but when you do, for God's sake don't cover your face with your hands and then mouth the word 'sorry'!" On the night, we pulled out the stops for the Britten, but the other we just winged. About three out of the two hundred of us were on the right page when it finished, and some I think had already left the podium. We got a standing ovation. (The strange thing is, I am not sure that the composer would have disapproved.)

Anyway, now the light has shone. Macmillan's modern Miserere was sublime, and even surpassed the genius of Allegri. It still had plainsong chanting. It still had blissful bursts of embellishment.  It also at times expanded to fill the Cathedral with thrilling perfection of resonance. But there was something new and bold and exhilarating, that, once heard, could not leave you in the same state in which it found you.

So here is my point. A new music is happening in Africa. Something new and bold and exhilarating, that, once heard, could not leave you in the same state in which it found you. Perhaps, I hope, you might even want to be part of it.

11. Us versus Mother Nature

11.  Us versus Mother Nature
22nd September 2013

In the six weeks since I left Berega, two mothers have died in the hospital. One young woman was unfortunate enough to develop eclampsia at 28 weeks of pregnancy. Pre-eclampsia, (the stage before eclampsia), is a malignant type of high blood pressure, which eventually picks off the organs one by one. Once the brain begins to be targeted, convulsions set in, and the disease is now called eclampsia. Treatment to hold back the fits and blood pressure can provide a window of enough hours to deliver the baby, and then to get on with bringing back the mother. 

The worst eclampsia cases often occur at a premature gestation, and in the UK, the obstetrician must weigh the whole situation in deciding the timing of delivery: here in the UK, delivering a baby at 28 weeks results in a 90% chance of it surviving. In Berega, the figure is zero. No-one will have time and emotional energy, however, to grieve the baby: the mum's life is the priority. Her brain, liver, kidneys, lungs, heart and blood have to be coaxed back to normality, in a part of the world where the nearest they get to Intensive Care is a blood pressure cuff that works, used by someone who knows what to do with the results. Even the IV fluids are home-spun and the 'giving sets' erratic. In rural Tanzania, many do not make it, and nor did this terrified woman or her baby.

Saving a woman's life once eclampsia has set in is like trying to prevent death from lion attack - it is only hard if you did not see it coming from a long way off. Eclampsia is usually preceded by weeks of symptom-free high blood pressure. This woman would have been fetching her water and cooking her ugali without ever being aware of the silent predator that stalked her, nor of the tragically few days she had left to live. 

I paint the picture in all its poignancy, to highlight the harsh injustice of Nature in the raw. The reason that Chagongwe and Mnafu and Maguha and Tunguli have two-hundred times worse maternal mortality than Estonia is not because the latter has an ITU in every village. They do, however,  have proper drips, and blood pressure cuffs, and people who know what to do with them. And roads. And systems of transport thereon. Preventing death from eclampsia is as simple as a village health worker (VHW) doing regular blood pressure checks, and referring in anyone whose BP is above a certain level. When I look back on my choice of career, this was a central influence: turning potential tragedy into joy by such easy means.

The other death was also deeply harrowing, and I will not give details. Suffice it to say that the problem was the combination of obstructed labour and haemorrhage, which conjunction is a grim reaper of young women in rural Africa. Again, in the final stages, the solutions are often beyond the resources of a hospital like Berega, but earlier on much can be done. Seeing the woman before the labour became obstructed would be a big advantage, and once more a VHW has a role in encouraging waiting at the 'waiting mothers house' in the hospital, when labour is approaching. This would especially apply to those for whom a troublesome labour might be anticipated - for instance a slim sixteen-year-old in her first pregnancy. Better still is for her not to get pregnant - but where does an uneducated village girl even  get the knowledge about contraception, far less the methods. Once more, VHWs can provide simple solutions.

It was a great joy, then, to help steer Berega's community development plan for mothers and children to its next stages. (see the updated blog post.) This began with triple and quadruple checking with the hierarchy at the hospital, and their advisors, that we have indeed captured their own vision, and that this is not something being done to them. Their response has been an overwhelming and heartfelt supplication that we might continue to make progress together towards the vision that they themselves set, (by candlelight in evening meetings in the mission house, was it just two months ago?) The repetitive listening process is a powerful instrument for change: sometimes it is only on the fourth reading of what will become our catechism, that we spot the flaws and subtext and difficulties. The major changes made so far reflect the importance not just of delivering babies safely, but of trying to prevent them becoming one of the one thousand under-fives that die in Berega's territory annually. 

Success will depend on bringing together as many as have a part to play. Three of the key agencies at the UK end are the Diocese of Worcester, the charity BREAD. and the charity Mission Morogoro. The latter two have as their entire raison d'etre the development of Berega, although coming at it from different angles, different parts of the country, and different funding sources. (Worcester Diocese has a wider brief of course, with the cure of the souls of half a million Worcestrians never something to be underestimated.) At the meeting we shared our different takes on how we might help in the future - and there are as many different takes as there are different needs. Achieving focus, unity of purpose, and division of labour is worth all the effort we will put into it. When obstacles inevitably arise, what controls our ability to remove them is not so much our power, as our combined determination.

Meanwhile, the Charter of Standards at Berega Hospital is being translated into Swahili, with the intention of giving a copy to each and every member of staff. Given that this strategy has come from the hospital management with no external influence other than initial catalysis, I am heartened to know that they really mean business.

Hands4Africa is another major player, and Brad has been honing down his thoughts and sharpening up his tools. We hope that H4A will be a major influence in working towards transport solutions. In this week alone at Berega there have been three major road traffic incidents, the biggest being twenty-five admissions in various states of broken-ness. They all survived. When the rains come, it gets worse.

Of course it is not only in rural Africa that such accidents occur, and blog readers will be devastated to know that I myself was unceremoniously unshipped from my bicycle on my first outing since my return. Coming down a hill towards a gate across the cycle path, my version is that I swerved to avoid a mother of quads, and, in a feat of acrobatic heroism, flung myself and the bike into a paratrooper shoulder-roll when the most vulnerable of the quads went back to pick up her dolly. My fellow cyclists' version is that I was going too fast, and sailed over the handbars like a flying frankfurter. Mother Earth eventually broke my fall by smashing my helmet into my head, in the process taking two inches off the length of my neck. Whichever version you care to believe, Mother Nature comes out of it as being hard and uncompromising. She needs us to take her in hand.

10. The Emaciated Mzungu Memorial Trench

10. The Emaciated Mzungu Memorial Trench
8th September 2013

Today it is raining, for the first time since my return. (Was that really three weeks ago?)

“That’s not rain”, a Tanzanian Crocodile Dundee would say, “This is rain!”, unleashing from behind his back a vast torrent, whence river and road became indistinguishable. Twice a year in Tanzania, the oceans and lakes and jet stream and sun get together, and for a few months fill the skies with surprised rivers, who had expected to be more terrestrial. They very quickly establish their fluvial rights, however, and pour down to earth, rushing in every direction in search of their familiar banks.

In the process, they make something of a mess of the roads. Months of sun will have hard-baked the dirt roads, but also fractured them. Then stones below the surface get dislodged by over-burdened traffic, and the fissures get wider. The more traffic on the road, the more the need for its integrity, but, ironically, the more the crunching and the cracking. Thereafter comes the rain, and the grateful river of water surges down the rifts, dislodges future silt, and leaves behind swirling furrows crossing the roads this way and that. During the rain, the dirt roads are all-but impassable, but when the sun comes out, it serves to dry the furrows into ruts and bumps that challenge even Land Rover suspension. And there aren’t many Land Rovers.

The front drive leading to our mission house was a case in point. The house, (as you will by now have seen on You-Tube), is tolerably comfortable, and the sitting room looks out over the steep valley to the hills beyond. Many times I have sat on the verandah, gazing emptily towards the dry river bed far below, wondering what to say in the next blog, but distracted by tantalising thoughts of distant sausages. It’s a beautiful valley, but as a result of its steepness, the rain leaves the front drive less a road and more an assault course. Being circular, the rain cannot simply run down it, and so reluctantly hacks it into furrows, as it charges down the hill towards a tumultuous reunion on the valley floor.

Water, however, despite its destructive capacities, is very biddable. It only turns your front drive into a ploughed field because it is trying to get out of the way, and if you give it the option of getting out of the way more easily, it readily accepts. Thus the Emaciated Mzungu Memorial Trench.

The story went like this: More than a month in to my stay in Berega, I was a wizened, puny vestige of my former self, with no opportunity to exercise, (other than lifting an occasional heavy pan of inedible yellow things, in order to discard them on the compost heap). On our visit to Dodoma, however, I saw a pick-mattock for sale, and pounced on it. A mattock is a beast of an instrument: Where a hobbit would use a hoe, a cave troll would use a mattock. It goes without saying, of course, that a pick-mattock is better for trench-building than a grubbing-mattock, because the pick-end enables removal of bigger rocks, whilst the mattock-end can hack out a trench, oblivious of roots and rubble. The entire tool, with handle, weighs about twelve kilogrammes. Having, with the pick, wheedled any stones out from the path of the mattock head, you then unleash the mattock onto mother earth, gashing a deep furrow in her flesh.

At the top of the drive, I planned the route that the water will take when the first rains arrive in November. Passers-by on the road stopped to admire the efforts of the emaciated mzungu, manfully standing up to the might of Nature, and pummelling the would-be trench into existence. Being out of condition, I had to rest after each blow. I would have rested half way through each, had it been an option. By the end of two hours, a few inches of trench were already demonstrating their proclivity, by directing a litre or so of mzungu sweat down the hill. From the boys of the village, flocking incredulously around, a polite murmur of what I took to be awed appreciation sniggered between them and the gathering mosquitos.

The path of the trench I sketched out by two parallel lines running down the side of the drive, and onto the thirsty lawn below. The first half-metre, mattocked to perfection, is a veritable Suez. Sadly, however, I did not get much further with the trench before I left Berega, and Sion has now taken over. As a result of his blow by blow assault on the un-mattocked section, an Emaciated Mzungu Memorial Trench is now being grooved into the erstwhile random surface of Africa.

It will be completed. We know what we want, we know where we want it, and we have begun. When the rain begins to fall, it may be that we will need to take account of the way water naturally flows, but thereafter it will flow with a sense of purpose, reinforcing the trench more deeply with each downpour. As the perceptive will have noticed, I have just managed to ooze my way into a relevant metaphor: Although I am now back with my own tribe, the journey to safe childbirth for future mothers in Berega’s territory has begun. Careful hands are now deepening the commitment and purpose and direction. Things may unfold differently to our plan, but perhaps not by much. There is no going back to the random inefficiency of the past. It will be completed.

Beautiful examples of the irreversibility are the inspiring activities of Kofia in Guildford and environs. Their thriving website is the hub of both fundraising and spreading of awareness, but I particularly love the fact that they have knitted nearly 500 hats for Berega babies – and arranged a means of getting them there. Part of the vision is that once babies have been delivered safely, (which involves staying warm), they will continue to thrive when they go back to the villages. We want to follow up women back in the remote parts, and help ensure that their babies grow into healthy children. Having a Kofia hat might become the hallmark of a new era of health for this new generation of babies.

Meanwhile Brad, from Hands4Africa, is enthusiastic and inspired by the idea of a combined assault of community development and a community-based maternal/child health programme in Mnafu. It will allow women with no current realistic access to health care to have their babies in safe settings, and to raise their children without the expectation that 10% will die. The plan will now be fleshed out, having now decided that in the first instance, the priorities are bespoke transport, and a health facility at Mnafu. Economic growth and education will follow, in partnership with the development of systems for safe childbirth and healthy under-fives.

The Diocese of Worcester has completed a hugely successful sponsored climb of Kilimanjaro, raising thousands of pounds. A dozen or so people, some of whom had suffered altitude sickness whilst training on the Malverns, nevertheless managed to conquer the mountain. It was salutary to note, when flying home, that the mountain top was nearer to the plane than it was to the plains. I would have paid thousands not to climb it, so utter congrats to those who even tried. Meanwhile, I have been humbled and touched by the support of friends and blog-readers; and of others whose catalysis I will talk more of next time – thank you. We are poised to make a difference where it will really count.

Meanwhile, back in Berega, progress continues. Isaac Mgego, the hospital Director, is mustering forces at that end, ready and eager to begin a new era. Last month we saw reliable electricity become ensconced at the hospital. This month, for the first time in its history, a blood bank opened. It sounds a small thing, but until now, if a woman were bleeding inexorably after delivery, we would first have had to call in a relative or a compatible donor before we could give her blood. Truly life-saving.

By the way, talking of life-saving, those following the tortuous tale of my nutritional nadirs will be delighted to know that my life is no longer in danger. I have eaten more Pork & Leeks and Spicy Cumberlands than any man’s gall bladder should decently have had to deal with. My blood pressure and waist size are creeping up nicely, and the sentinels of my liver have sent out for reinforcements. Furthermore, my exercise tolerance is beginning to build, and my legs no longer look like articulated wooden spoons. Part of the de-wooden-spooning programme is country walking, and so it was that on Tuesday we went to the Peaks, and I once again immersed myself in English countryside. In the evening, pleasantly aching from ten miles of Derbyshire tracks and trails, fields and villages, woods and rivers, steep slopes up, steep slopes down, and even some steep flat places, all leading to deep satisfaction of arriving back where we had started from, I sat in the garden of the Devonshire Arms, and got outside a home-made game pie and a pint of ale, watching a yellow wagtail hop around the stones of a fresh, lively English stream. I was very satisfied to be home.

The next day, the full English breakfast strengthened me for the shock of the bill. A night in an English inn costs more than a month’s living costs in Berega. In fact I do seem to have overdone my response to the rediscovered capacity to spend money, which I was anyway always quite good at. In Tanzanian terms, my income is like the spring rain flooding down across my life, washing this way and that in lavish exuberance. I suspect that Mis (my wife) thinks I need mattocking. 

For reference: Berega Hospital Development Plan for Health of Mothers and Children - Fourth Draft

Berega Hospital Development Plan for Reproductive Child Health

(RCH - Health of Mothers and Children)

(draft 4)

The Problem

Tanzania has one of the worst maternal mortality ratios in the world¹, mainly due to the combination of poverty, lack of education, lack of understanding of disease, long distances, poor family planning, and poor transport.

Furthermore, the rate of neonatal and child death is probably even more serious², but currently difficult to measure in impoverished, isolated rural parts of the country, where as many as 10% of children are expected to die before their fifth birthday. Chronic malnutrition contributes to almost half of these deaths.

Within this context of rural Tanzania, Berega Hospital serves a vast and inaccessible territory of approximately 100 x 70km. This area has just two tarred roads, and, according to the 2012 National Census³, a population of 217,000. Extrapolating from the national data, there are 8,500 births/year, of which only 1000 occur in a health facility.

Many roads are impassable in the rainy months, and others are only negotiable by long, expensive, and dangerous three-person motor-bike rides, (comprising for instance a driver, a labouring woman, and a carer/blood donor). Berega provides the only Comprehensive Emergency Obstetric Care (CEmOC) facility in this territory – ie capacity for caesarean section. Even for those few who live near the main roads, travelling to any other CeMOC facility is both unaffordable and impractical, (70km to Kilosa; 110km to Morogoro; 180km to Dodoma).

Millennium Development Goals (MDGs) IV and V from Tanzanian 2012 census

Of particular importance in developing the health services of this area is the need to address the MDGs IV& V – Under-5 and Maternal Mortality. The national census³confirmed that the rural areas have a particular problem, made worse by the lack of education and lack of access to birth control. Women have large families, and expect some of their children to die – and even perhaps to die themselves.

The maternal mortality ratio for Tanzania in 2012³ was 454 women dying for every 100,000 live births, (ie 0.45% of mothers die in each childbirth). The worst in the world is 1100¹, (1.1%), and the best is 2, (0.002%). As the Tanzanian figure is the average for the entire country, it is likely that in isolated rural areas, the figure for mothers who die in each childbirth is nearer to 1% than 0.45%.

This means that in Berega’s territory, at least 40, and perhaps as many as 80 women per year die in childbirth. Many more suffer chronic disability, such as vesico-vaginal fistula, (VVF). VVF has a profound effect not just on the woman but on the family – she leaks urine from the vagina 24 hours/day. This makes it very difficult for her to live in the cramped conditions of rural village life, and yet the survival of the children depends on her.

The 2012 Census under-5 mortality figure for the country was 8.1%³. This figure will be a considerable under-estimation in the isolated rural areas. This compares with, (for example), 10.1% in Afghanistan², and 0.2 to 0.5% for most European countries.

In Berega’s territory, where there are 8,500 births/year, this under-5 mortality rate means that perhaps as many as 1000 of these will not reach their fifth birthday, mainly due to the combination of poor nutrition and chronic but easily treatable disease. The under-nutrition is a vital component of the mortality, because of its effect on reducing the capacity to resist illnesses such as diarrhoea and pneumonia. In impoverished rural areas, many children survive mainly on thin porridge, (‘ugali’).

In Europe, North America and Russia, less than 2% of the population live on less than $2/day⁴. In Tanzania, the figure is nearly 90%⁴.

The Vision

The vision is to reach out to isolated communities, working with the Traditional Birth Attendants, (TBAs), VHWs and village leaders, to develop a system of assessment and early referral of women with problems in childbirth. The TBA would accompany the woman to hospital.

Furthermore, Berega's outreach to these communities would work with both the TBAs and trained Community Health Workers^5,6 in a partnership to enhance ongoing maternal-child health and nutrition, eg improving child nutrition; recognition and early treatment of severe or chronic illness (such as malaria, anaemia, diarrhoea, TB, infestations, HIV); immunisation; registering families and following up the disadvantaged; and family planning. CHWs will also help improve collection of information – eg demography, birth rate, etc.

This would be happening in the context of an integrated community development driven by a planned partnership between:

· the local community;

· Berega Hospital;

· the American community development charity Hands4Africa, (H4A);

· the UK Berega charity Berega Relief Education And Development, (BREAD);

· the UK maternal health charity Ammalife;

· the Anglican Diocese of Morogoro.

The aim would be the enhancement of the transport, data collection, economy, education and facilities for currently isolated communities. A number of other charitable organisations are interested in providing start-up support, for instance the Diocese of Worcester, and Kofia.

The Strategy

We have selected the community of Mnafu to begin the programme. The aim, ultimately is to reach a point of self-sustainability in health and community development. We will only to move on to address the needs of other isolated communities, when we feel that we have learnt sufficient lessons from Mnafu, and when to move on will not reduce the prospect of Mnafu and the surrounding communities achieving self-perpetuating development.

Phase 1A: Community Base - Reproductive Child Health CHWs

At the centre of the project will be bespoke Community Health Workers, learning lessons from and communicating with similar Tanzanian projects^5,6. A team of mature, trained^,7,8,9female RCH Community Health Workers will approach the community of Mnafu. At first they will be accompanied by the Project Lead Dr. Abdallah, (who is also the Head Doctor of the hospital, and Maternity lead. He is just completing his Masters in Public Health, with a specific interest in maternity outreach in rural Tanzania). The CHWs will be recruited from staff who have worked for many years in maternity in the hospital.

Their role in the first year will principally be the gathering of information, and the establishment of partnership. Amongst other duties, they will need to:

- Meet village and school leaders and establish credibility and shared purpose;

- Meet mothers and hear their story, and learn about their perceived needs;

- Meet TBAs and learn of their practices, their concerns, and their ideas;

- Meet Village Health Workers (VHWs) and discover what records and registers they keep, what the problems are, and what their thoughts are on solutions and priorities; (For the purposes of this paper, the distinction between VHWs and CHWs is that the former are villagers based in the community, whereas CHWs are health workers reaching out from the hospital¹⁰ . Nevertheless, there is considerable cross-over in the literature between the two terms.) Where there are no VHWs, the CHWs could help in establishing them.

- Discover what currently happens when there are problems in childbirth;

- Assess other health issues relevant to health and well-being of mothers and children, such as malnutrition; family planning; HIV; STDs; TB; Malaria

- Discuss with the appropriate people about systems for ‘Road to Health’ charts, in particular for monitoring growth and immunisations in pre-school children. This would, in the fullness of time, work alongside a mature schools health programme for children of school age.

- Attempt to obtain raw data on rates of death and serious complications, and try to enhance future collection of such data;

- Assess the current frequency of attendance of women from Mnafu (and environs) to Berega, and determine what problems they come with, and what outcomes currently occur.

Whilst this is occurring from the hospital side, H4A, using their own funding, would have begun their programme by enhancing the transport possibilities from Mnafu. At the same time, they would have begun the negotiations to begin food and cash-crop agriculture to the community, as well as to begin the building of a facility which in future could be used as a clinic.

Phase 1B: Hospital Base

At the same time that these beginnings are being made in the community, the hospital will be looking internally at its processes and patient pathways, to optimise the care for mothers and babies when they reach the hospital.

In relation to mothers, minimum standards of care have been set out in a hospital charter, which came from the hospital staff themselves, in order to work together to improve outcomes. An example is the 30-minute decision-to-readiness time for emergency caesarean. The entire Charter is available on the blog site.

With regard to children, Phase I needs to concentrate on:

- Emergency Triage Assessment and Treatment, (ETAT), which involves the recognition of sick children, and appropriate management, especially in the first 48 hours;

- Ward protocols for the Children’s ward and the Premature Baby Room, to include screening for and treatment of malnutrition (and any underlying causes), as well as routine daily feeding of children;

- The initiation of Road to Health charts for those under-5s that do not have them.

Phase 2

When trust and partnership have been established, the next phase of work would be to begin to bring women into Berega for giving birth. Whether this were all women, or selected ones, would depend very much on the results of liaison with the TBAs. There may be local solutions to some of the problems, and these should not be ignored.

It is clear that, given the long distances and the speed with which complications can occur in labour, the ideal would be for all women to deliver in a CeMOC facility. This, however, is impractical for many years yet, and the project will explore the most suitable working compromises – which will evolve with time.

When the transfer policy is decided, one potential model is that TBAs will thereafter accompany women-in-need to hospital for childbirth. Whether they will be paid a small amount for their involvement will depend on how the plans unfold after community liaison, and will be heavily influenced by policy and evidence. Whatever model is adopted, it will need to be self-sustaining financially. There is, however, considerable scope for this, given what families currently pay – for instance for those women who transfer in using private transport, and subsequently need to pay for caesarean and /or extended stay.

When women have successfully followed this pathway, and delivered healthily in hospital, these will then become ‘flagship pregnancies’. The RCH CHWs would follow-up those women and babies back in the community, to try to enhance breast feeding, family planning, immunisation, growth charting, under-5s nutrition, and prevention and treatment of diarrhoea, malaria, worms, and other chronic conditions. This would be centred at a purpose-built health and community facility.

At the same time, registration of families would help ensure that no-one was left behind and that measurement of the effects of intervention might be realistic.

The aim would be to produce a high-profile cadre of mother and babies who have survived childbirth and early child-rearing healthily. These would then encourage others to do the same.

Phase 3

Assuming an appropriate unfolding of the first two phases, the need would then arise for fully staffing the clinic facility at Mnafu, upgrading its resources and equipment, and later providing a birthing facility for uncomplicated women. The upgrade of the building would be provided by H4A, in association with the community itself. 

In relation to staffing, and in readiness for arriving at phase 3, Berega needs now to begin its application to begin a Clinical Officer (CO) training programme. In rural Tanzania, COs are the front-line staff. Having achieved a high standard and good grades in high school, student COs are trained for three years in the management of childbirth, and of all common illnesses. Clinical Officers can staff a clinic and birthing facility, and are especially taught in regard to the recognition of those patients who need to be transferred to hospital.

Not just COs but also nurses are needed for dealing with the extensive health care needs of Berega’s population. As with COs, it is important for Berega to have a sustainable strategy of training its own nursing staff. The existing nursing school (SONAB), which trains to Diploma level, recently had its first graduation but is only part-way through the staged expansion to full capacity. It is vital, then, that the growth of CO education does not impede the completion of SONAB’s plans, but rather works with it in collaboration, and enhances it.

Fundraising for building the classrooms, offices and student accommodation for this combined ‘Health Education Institute’ has already begun. There are significant set-up costs, especially in relation to buildings. The SONAB building plans will be melded with the CO training needs, to produce a composite building strategy. This will mean that the funding gap in CO and nurse education will be principally in the first three years. These costs will be considerably reduced by the existence of H4A’s already-purchased compressed earth technology, which will provide very high quality building materials at the lowest possible cost.

After the buildings are complete, fees and other income of the Health Education Institute will need to be set at a level which is self-sustaining, and which will pay for both the faculty and the day-to-day costs.

Plans are being developed for recruitment of a supplementary visiting faculty to enhance the training at no extra cost, enabling the School in future to be self-sustaining on training income.

Phase 4 – the long term vision

As educational opportunity improves for the children of Mnafu, we hope eventually to be training as nurses and COs youngsters who have come up from Mnafu schools. COs, after practising post-qualification for a minimum of two years, can then carry on and be trained as ‘Assistant Medical Officers’ (AMOs), who are in effect the doctors and obstetricians in rural Tanzania. Although the tendency is for COs to look for work in less rural settings, it would only take a few of the best students to stay on, to enable the gradual building of a motivated and locally-derived sustainable workforce. The same comments apply to senior nurses and to future educational faculty.

The cost of expanding the staff of Berega to offer positions to graduates of the School would be readily covered by the increased income related to numbers of patients treated. In maternity alone, there are more than seven times as many women currently delivering in the community as deliver in the hospital.

Once CO training is established, and both hospital staff and training faculty are self-perpetuating, it raises the prospect of future expansion of the School of Health, for instance to increase training of laboratory workers or CHWs.

The long-term vision is to have an economically viable community, with good health and educational facilities, and a lattice-work of COs, CHWs, VHWs and TBAs working within a well-oiled mechanism for early transport of the needy to high quality high-tech facilities at Berega Hospital.

As soon as the lessons had been duly learnt from Mnafu, Berega could then begin outreach to another community in need, until all of the isolated communities have been reached.

References

1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries

2. http://data.worldbank.org/indicator/SH.DYN.MORT

3. http://www.nbs.go.tz/takwimu/references/Tanzania_in_figures2012.pdf

4. http://en.wikipedia.org/wiki/List_of_countries_by_percentage_of_population_living_in_poverty

5. http://www.ihi.or.tz/projects/the-connect-project

6.   http://1millionhealthworkers.org/2013/04/15/tanzania-hosts-global-one-million-community-health-workers-campaign-forum/

7.   http://www.frontierus.org/documents/FREP_Reports_2012/FREP-Community_Health_Worker_Care_Coordination.pdf

8. http://www.cdc.gov/dhdsp/docs/chw_brief.pdf

9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3343233/?tool=pmcentrez&rendertype=abstract.

10. http://www.ncbi.nlm.nih.gov/pubmed/2363189

For reference: Some video clips!

At last back in the world of fast internet, I can give you some moving pictures! The road to Mnafu shows the beginning of the road from the hospital. Mnafu is about an hour further on.

Road to Mnafu:  http://youtu.be/cDGP2GJRWuA

http://www.youtube.com/watch?v=cDGP2GJRWuA&feature=youtu.be

Hospital House: http://youtu.be/n84o3Mztf9o

http://www.youtube.com/watch?v=n84o3Mztf9o&feature=youtu.be

Berega Hospital: http://youtu.be/D9YBOYn10FA

http://www.youtube.com/watch?v=D9YBOYn10FA&feature=youtu.be

Sion Bird: 

http://www.youtube.com/watch?v=M0MYNAN98aI&feature=youtu.be