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?"

23. Agnostic Oats

Agnostic Oats
25th April 2014

What's in a name? 

When they were setting up Amazon, there was a competition to decide the name. They wanted something that would convey the ideas of selling; quality; value; and quick delivery. My suggestion was 'We-sell-quality-stuff-cheaply-&-get-it-to-you-quick', but, in an uncharacteristic moment of corporate short-sightedness, they decided not to go with it. They chose 'Amazon' instead. They reckoned that the implied ideas of massive and endless flow of life-giving fresh water, carrying with it the capacity to decimate travelling times and difficulties, might give the customers the right feel.

Furthermore, of course the Amazons were the only race ever known in which the women had the power. If an Amazon wanted a new warrior outfit, and wanted it quickly, she would simply summon her fastest slave, and dispatch him off to Byzantium with a few drachma captured from a Trojan on her last trip to the coast. With a hurried, 'I hear and obey!', off he would trot, not resting until his mistress was slaughtering the Phrygians dressed in this summer's colours. The name 'Amazon', then, for an on-line selling company, not only gives off an aroma of all the glories of the largest river in the world - fresh, all-compassing, problem-solving - but also has a hint of unfettered freedom for women. Had the largest river in the world been called 'Attila', doubtless my suggested name for the emporium would have had more chance.

The bottom line is that names matter. Gorbachev needed 'Glasnost' to tackle the more sinister aspects of the USSR. Lincoln needed 'Emancipation' to free the slaves. Ferguson needed 'Manchester Untied' to persuade plutocrats to part with eight-figure sums. Had Hamilton Academicals had a similar run of success to United, they perhaps would have run into merchandising difficulties. To drive the point home, would the US Defence output be quite as awe-provoking if it came from the Dodecahedron? Would 'Agnostic Oats' work as well as 'Quaker'?

And so it was that the name 'EMBRACE' evolved to convey a bold attempt to reduce the wastage of life in rural Tanzania. It stands for 'Empowering Women & Children to Receive Adequate Care and Equality', and it endeavours to do what it says on the tin. The idea of caring and collaboration that the word conveys, adds exactly the right flavour. 

However, of course it only does so in English. In Morogoro region, English is the third language, and Swahili is the common tongue. The nearest word to 'embrace' in Swahili is 'embamba', which means 'thin'. Not ideal.

On 9th April, the whole management team of Berega Hospital met, with one purpose: to come up with a Swahili name for EMBRACE. The fact that they did so, by the way, is a tribute to their growing excitement that this might truly be the start of something important for the families of the area, for women, and for childbirth. That excitement is due in no small part to the widespread support in this country for the idea of EMBRACE, not least from you, the readers of this blog. The meeting was a success, and EMBRACE is now 'EMBRACE - Tushikamane: 'We are in solidarity'. I append Sion's email below.

So what's in a name? The answer is that a name helps people to share the same view, to build up impetus, and, where there is something to be done, to take a fresh look.

Tushikamane! I hope you are too!

(By the way, the is the first of a much shorter blog, with the idea that short-and-often is more appealing to sentient beings than once-when-you-feel-like-it. I hope you approve - but let me know either way: email.lozza@gmail.com)

Sion's email of April 9th 2014:

After much animated discussion in the management meeting today we have decided on a project name and subtitle byline for EMBRACE:

Tushikamane

Kupunguza vifo vya wajawazito na watoto

Tushikamane = 'We are in solidarity' (this is the overall name- like 'embrace')

Kupunguza vifo vya wajawazito na watoto = reducing deaths in pregnancy and childhood.

We liked that it expressed the sentiment that we want to work in solidarity with the mothers, the village leaders, the fathers and the TBAs in improving the safety of delivery and early years care. Even the HIV programme 'tunajali' (we care) is a bit  paternalistic, so the tone we are setting is one of cooperation. It was agreed by all Swahili speakers that the term would sit well in the minds of the people we wish to work with, and would send out a strong diplomatic message.

Dr Abdallah came up with the title, chosen after contributions from all management members, and we all worked on the subtitle.

Hope you like it!

Sion

One day, this village clearing might be the meeting place for Tushikamane...

22. Woman Power

Woman Power

 28th March 2014

The answer is 1metre 80cm, (5ft 11inches). This titbit of knowledge is so surprising, (nearly six feet!), that to call it ‘trivia’ is demeaning.

The question to which this is the answer is, of course: ‘How tall was Mary, Queen of Scots?’ (Eventually.) (Not counting the last couple of minutes.) Mary Queen of Scots was the grand-niece of Henry VIII. She was Queen of Scotland from infancy; was Queen of France un peu; and was mother of King James I of England. She was taller and better educated than just about anyone on the planet in the sixteenth century, and possessed compassionate beliefs and sparkling social skills. And yet, she never had power. She was made use of by her men; spent half her adult life imprisoned; never saw her son again after his last breast feed; and, finally, was beheaded when they could not think of anything other use for her.

You do not need to be much of a feminist to feel that she had been somewhat simon-cowelled. (Cockney rhyming slang for ‘disembowelled’ – itself a metaphor for humiliation of the vulnerable by a dental flosser*.) (*More Cockney rhyming.)

Before I became an obstetrician, I was an alpha male rugby-playing surgeon, and, rejecting the stereotype, never thought of myself as much of a feminist. Indeed, despite living then in a world of burgeoning gender equality, I am ashamed to say that, in my ignorance, I vaguely thought of feminists as women who wanted to be like men. It was only when I came to a deeper maturity that I realised that no insult could be more below-the-belt. Why would a woman want to be like a man!? Of course, not all men historically were bombastic, insensitive, dominant, aggressive, grumpy, sex-mad, power-crazed odd-job men, but as a gender, over the millennia, we have indeed done our share of sulking angrily at the lack of sexual responsiveness of a vulnerable and abused mistress, whilst putting up a shelf. True, many of us were good for fighting off lions, intruders and money spiders, but I have to accept the argument that this might not have been sufficient recompense for childbirth, home-building, and disempowerment.

Fortunately, here in the UK we have mainly left behind the epochs of gender stereotypes, in theory at least, and my wife these days expects me to share in the cooking, just as I expect her to help in the turning-on of the computer, to try to fix the black-screen-problem.  

However, this balmy concord in the division of household chores nevertheless remains the exception rather than the rule in many parts of the world, and in particular in rural Africa. In the recent past, men were the workers, and before that the warriors, and roles were tough on all sides. So much has changed that it is now impossible to make sweeping generalisations. Yet it remains a grim fact that many women are born to a life (and death) of recurrent childbirth, bereavement, toil, and exhaustion. This is not necessarily because men choose that it should be so, but rather this is the way that it always was. In the sleepy heat of the African sun, somehow things never get round to being different. It is accepted.

What has proven most effective in changing this, in developing countries on every continent, is the empowerment and education of women. Once women start meeting in groups with the purpose of discussing their difficulties, and once this process has the blessing and cooperation of the men, (which it often does), then suddenly barriers which had seemed insuperable to the individual, melt, like glaciers in Surrey. (A strange simile, I hear you say, but do you see any glaciers in Surrey?) Solutions emerge. An interesting characteristic of solutions, by the way, is that they don’t have to be right. They just have to be tried, and the process leads you another step ahead. Suddenly people are asking why they should have six children; why they should not have cleaner water, nearer by; why they cannot create employment; why bare subsistence should be the norm; why their children cannot go to school; why they should be so susceptible to ill health; and why they have to die to bring life into the world.

After many iterations, the project EMBRACE (Empowering Women & Babies to Receive Adequate Care & Equality), has now defined exactly how it plans to tackle the complex and interwoven problems underpinning death of mothers and babies. And it has taken its first baby steps.

The planning of an intervention to be ‘done to’ a community is fraught with difficulty, and, ultimately, is likely to founder in the mire of Unseen Difficulties. This has been the troubled history of African development: “When you do what you always did, you get what you always got.” On the other hand, when communities have only hope rather than expectation that anything should ever be better, how do you get them to want the interventions you have up your sleeve?

Women’s groups have provided the answer, and I have pointed in the past to this heart-warming video:

http://vimeo.com/12427420

It was with great pleasure then that I have been receiving the emails from Elizabeth Ali, and Drs. Sion, Ahmed and Abdallah about progress that has been made. Two points need highlighting in particular. The first is that Sion and Abdallah met to finalise the methodology that EMBRACE will be using. They have discovered that a village infrastructure exists, which can be tapped into, and harnessed for whatever development needs are being addressed. We had no idea that this infrastructure of hamlet leaders, village health workers and traditional birth attendants was already formed, but relatively dormant, in every community. It gives us a powerful way in, for the formation of women’s groups. Once the touchpaper has been lit, we then hope to muster, direct and coordinate support, so that issue by issue the communities can begin to tackle their pressing problems. 

I will post Sion Williams’ summary in full on the blog site, but here is a distillate:

"We must first identify areas with problems- so far this includes Berega, Tunguli and Mnafu. This requires the mapping. Next we meet with four key groups of people - TBAs, village health workers, hamlet leaders and village leaders, to get them on board.

We will ask these community leaders to identify appropriate women, to become key people in the running of the groups at hamlet level. 

The purpose of these groups is to first identify problems, which will then inform the next stage of the project- getting people to deliver in a GOOD SAFE hospital.”

The second breakthrough has been in the mapping. It turns out that the hamlet leaders already know much of the information that we need. This means that we can simply go to each hamlet, meet the key people, explain what we are trying to do, (with cautions about raising expectations too quickly), and then measure GPS coordinates. (Look at me, using terms like ‘GPS’ as if I had been raised on Google Earth. If the truth be known, until last September I had thought it meant ‘Gherkin & Pastrami Sandwich’, and I had always puzzled how New Yorkers used bread products to find their way around.)

Again I quote Sion:

No good maps exist of the tangled motorbike tracks and sporadic hamlets from which labouring mothers travel from when deliveries go wrong. Today we started an innovative new project with Mission Morogoro, Hands 4 Africa, Ammalife and Google Maps to accurately map these distant settlements. We are visiting settlements by motorbike, recording coordinates, and hearing the stories of the most important people- the remarkable mothers who brave childbirth in a mud house, by kerosine lamp light, hours from medical help.

The battle against maternal mortality starts with finding, listening and working with these women. Only then can we bring these communities into the fold of the hospital, working with them as equal partners. But ultimately it starts with the map.

Pictured: project technician Abdallah Mondo records the coordinates of Kiegea village. Last year his first son was born safely in the hospital and he is committed to helping other women do the same.

Sion highlights in his messages the awful consequences of the bridge collapse, and the repercussions on the hospital. It is a double whammy: the patients cannot get there, so income cannot be generated to pay staff; meanwhile the bill for bringing in drugs and other resources has gone through the roof, because of the hundreds of kilometres detour on bad roads the transport from Morogoro has to take.

My own hospital in Coventry is six times the size of Berega, and its annual budget is £1bn. Berega’s budget is less than £150,000. (£1k/year is a good salary in rural Tanzania). To save you doing the maths, that means we in the UK are spending 1000 times more per bed on the hospital - not counting GPs and all the other available health facilities. Nevertheless, in Tanzania this money is increasingly impossible to find with the bridge down. And no money means no malaria drugs, no antibiotics, no staff – lives will be lost. They have launched an appeal. Can you help? If so, please email me at email.lozza@gmail.com, and I will send you details of how to send money.

The bridge, however, will be rebuilt this year, and we must be ready to continue our impetus in helping make childbirth and childrearing the beautiful and safe experience we should like it to be. 

We have begun the process of empowering women, and there is nothing in this continent more likely to produce good. I really hope that Mary, Queen of Scots, will be smiling down on our efforts.

                                                                                                                                      

21. The planned way ahead for EMBRACE - Guest blog Dr Sion Williams

28th March 2014

Following many months of planning, we have got to the point where the theory and the practicalities need to be reconciled into a practical way ahead for the EMBRACE project. This can only be done on the ground, by those with local knowledge, who intend to be part of the process.

To this end, Drs Sion and Abdallah recently met, and have sketched out exactly how the project is to begin. The longest journey starts with the first step, and many never make it that far. As you see below, however, the boots are on, the door is open, and the map is in hand. Here is Sion's recent email:

"Myself and Dr Abdallah sat down for an hour this morning to dicuss how he forsees the practicalities of how EMBRACE may work. We are in agreement with what most have said so far, with a few specifics on how we go about the process of outreach. We are also aware that improvement of the hospital comes first.

We must be cautious also not to get carried away- the immediate concerns of the hospital are a dire finanancial state due to government and NGO cuts, and the collapse of the bridge. It is important for the future survival of the hospital that we increase its utilisation, but do be aware that as much as we want to improve things, with falling revenue and patient numbers we are struggling to maintain the status quo.

Based on local knowlege and wisdom the conclusions were this:
We must first identify areas with problems- so far this includes Berega, Tunguli and Mnafu. This requires the mapping.

Next we meet with four key groups of people- this will be TBAs, village health workers, hamlet leaders and village leaders. The purpose of this will be mainly to identify women of child-bearing age (WCBAs) and also to get these 4 groups of people on board. From Abdallah’s survey he found that often women want to deliver in a health facility, but that the decision makers and main influencers in the village were not the women themselves but the hamlet leaders, the TBAs, and community elders.

We will ask these community leaders to identify appropriate women, even to go as far as asking them to form and become key people in the running of the groups, at hamlet level. The purpose of these groups is to first identify problems, which will then inform the next stage of the project- getting people to deliver in a GOOD SAFE hospital. The point of getting the TBAs/leaders/elders involved at the outset is that without their support it will be very difficult to implement solutions to problems raised by the discussion groups.

Again, a key point raised was how do we evaluate the efficacy of this? We agreed that the first thing to do was to establish what is going on now. This can be done in 2 ways:

1.    Going through hospital records to record locations of where people have been coming from to deliver. Furthermore, once we have good village level population figures we can then highlight maternal blackspots in our territory. This is being done as I write.

2.    Another way will be doing surveys (as a parallel to the mothers groups) in the areas of interest- for example trying to get an actual snapshot of institutional delivery rate (ie. How many women are actually delivering in a hospital) and also by estimating maternal mortality in our territory as it currently stands (see the sisterhood method for evaluating maternal mortality http://www.who.int/reproductivehealth/publications/monitoring/RHT_97_28/en/

Thereafter, we must evaluate whether our interventions have been effective- both for our own improvement, and to increase thelikelihood of getting grants in the future. This could be done as a
‘Project Evaluation’ or even more academically as a study- perhaps with cluster randomisation to compare like villages, or before and after ‘survey’ methods in the village of interest (surveys will
probably be easier and more practical- EMBRACE is a pragmatic rather than a purely academic undertaking). 

It is a long road, but we have begun.

Best wishes

Sion

PS

See this study where they have done almost exactly what we want to do in southern Tanzania: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858713/"