Real Politick

Currently there's a song doing the rounds on my Ipods 'on the go' list. The
opening line goes 'God please bring the rain, make it soon'. (Ryan Adams,
The Shadowlands, Love Is Hell Part 1 EP, for those who are interested!).
This always raises an ironic smile, rain is at least a month off and it is a
thermometer busting fifty-two degrees for a few hours most days. The ground
has lost all semblance of vegetation and so the wind carries sand and grit
in thick clouds across the clinic. If you happen to be outside as this hazy,
gritty veil descends the only thing you can do is put your head down and
wait for the cloud to pass as visibility drops to just about being able to
see your feet.

I've just had a short break in the outside world, which was great, if a
little odd. On the first afternoon, I plonked myself down in front of the
bastion of intellectual journalism Sky News. One of the stories I watched in
dumbstruck awe can be paraphrased as follows. Ricky Martin (the term 'Latin
pop sensation' was used more than once in two minutes) was recovering from
the loss of his personal mobile phone with (and this quote was so good I had
to write it down!) 'Personal numbers and addresses contained on it' however
brave Ricky still managed to put on a good concert in Sao Paulo. The
reporter then interviewed people leaving the concert and asked if they had
enjoyed it, to which they replied yes. Words fail. Thanks a bunch Rupert
Murdock. Any updates on whether the phone was ever recovered would be
greatly appreciated. This corner of Africa waits with baited breath… maybe
it's with Rhonda…

Anyway this week my outreach buddy has been off doing a meningitis
assessment and I've been hiding in the TB clinic trying to stay out of some
of the teams burgeoning issues with … er…each other!!! I really can't be
bothered to go into the whole thing, basically Babbage didn't slave away
inventing the computer only for me to use it to moan. A good friend of mine
who's been involved in this sort of caper before e-mailed to muse that even
' hundreds of miles away in a totally different world - you still have
office politics! Grrrrr'. You can't put a group of complete stangers in the
same place for months on end in what, at times, can be an immensely
stressful situation and not expect the odd problem.

I've adopted a Swiss approach of staying out of the way until the verbal
bullets
have stopped flying. Obviously it's not as straight forward as this, and
everyone seems to have an opinion and an oar poised to be stuck in!!! Anyway
luckily I'm not in the firing line and, as ever, I seem to be given my own
free reign to pretty much do what I want, which is lovely. I've also got a
list as long as an orang-utans arm of things to catch up on so I'm not
exactly idle.

Having said all that, far more challenging than any of this has been the
patients we have seen this week. Perhaps the saddest has been a woman who
attended with acute psychosis. The history is vague and there are hushed
whispers of possession by evil spirits and curses.

After she first became ill, and very agressive, the family, were unable to
deal with her safely and so did the only thing they thought would help, they
tied her to a tree for three days. Finally they brought her to us. 'They
said she tried to bite them' said one of the health workers as we tried to
investigate. I have to confess that if someone had tied me to a tree for a
few days I would view this as a reasonable course of action. This point
seemed to get a little lost.

She had kicked and struck out at anyone of her family who went near her. The
first thing we had to do was untie her hands, which were bound with thick,
chaffing, rope. She lay on the ground, with a terrified look in her eyes as
we approached her, very slowly. Rather like bomb disposal or going on
Celebrity Big Brother this, clearly, had the potential to go very wrong
indeed. Before we attempted this I must confess there was a syringe with a
hefty dose of Diazepam in my back pocket. Thankfully the most I got from
this poor woman, upon her release was a rather overly enthusiastic hug.

Sadly, the only way we can deal with this problem presently is anti
psychosis drugs and very heavy sedation, just so she doesn't hurt herself.
We are going to bring members of her church to speak to her this week and
see how it goes. This countries scars run so deep, I'm not sure a lifetimes
worth of counselling would even scratch the surface.

Otherwise I've got my TB team doing a teaching session for me on local
culture in return for half an hour on the side effects of TB drugs.

If you are a child the only side effect seems to be that they make you
insanely happy. The compound where the TB patients are is always teeming
with children, quite who they all belong to I'm not sure. Thankfully after a
fit of laughter most of them let out a rough, gurgling cough, thus
justifying their presence. I've taught most of them to pull faces, and blow
raspberries which has, obviously pleased their parents no-end. No one can
say I haven't left a legacy.

Match Of The Day

After the brief restbite of vaccination, I've spent end of this week cooped
up in an office tying up various loose ends. The monthly statistics , and
various contract wrangles have taken up days on end. I doubt if we will sort
out all the contracts by the time it is time to sign the new ones next year.
Selfishly I won't be here when that happens so I can very much pass the buck
and just concentrate on this years organisational disaster. Which, frankly,
is more than enough.

I think my essential problem is that there are too many 'Mary's' in this
country! Out of a staff of fifty five I have to supervise eleven are called
Mary! This country gives it's people a plethora of names after their first
name. All are similar sounding similarly spelt, rather like China (which I'm
told only has four variations of surname!) and the vast majority of them
begin with the letter N, Vowels pop up in perculiar places and the whole
notion of words being spelt like they sound is clearly alien here (the 'TH'
sound, sounding like 'si' anyone?)

The contracts of two Marys were mixed up and sent to the wrong clinics,
signed by both of them and sent back, so now I've got to go through the
whole process all over again. Included the dreaded social insurance form. If
I'd really appreciated how time consuming it would be to get the contracts
for the Marys (and the others) sorted I would have probably filed them in
the bin at the beginning. That a country lacking in even the most basic
healthcare infrastructure can construct such an impressive assault course of
bureaucracy is baffling.

I'm never going to call any future offspring Mary out of protest. If all the
currently employed Mary's all did different types of jobs we would have
enough of them to staff an entire clinic with people called Mary. Or, to put
things another way, and the link is a little tenuous I grant you, we have
enough Mary's to make a football team. Which neatly leads me on to my
Saturday afternoon activity

Some of you, I'm guessing, may have watched a game of football this weekend.
The particularly active ones might even have kicked a football round the
park or played in a more organised game. I spent the afternoon playing a
game of football like one I've never played before.

The teams were mainly members of our staff. All in their mid twenties, like
me, all very keen on football, like me, all able to play high tempo football
in forty degree temperatures with apparent ease and there the similarity
ends!

The match was conducted on the airstrip, the only area of flat land without
scrubby bushes. The ball was a nice new one we had flown in. The goals were
hastily erected sticks. The referee dispensed with the more usual black polo
shirt and shorts and instead went with a long flowing white robe and a
cowboy hat.

Most of the players opted to play minus shoes but from the power with which
they hit the ball and the boldness of the tackles you would never have
guessed. I had told myself that getting injured doing this would be a
particularly stupid thing to do, so any tackle that looked a bit dicey I
stayed clear of, making look like a complete wimp.

In their ultimate wisdom, my team decided that out on the right wing was the
place for me. If I'm honest I think it is because they wanted me out of the
way. When David Beckham plays on the right wing he does so with gusto
running for miles on end up and down the line sending in cross after cross
with laser guided accuracy. When I play on the right wing I flail around in
the manner of a lost lunatic. If the ball ever heads my way I try to do
something productive but inevitably end up apologising to my team as the
ball sails out of their reach. Very much a squad player me.

The game was interrupted by several pitch invasions, firstly by a group of
moping donkeys and then by a group of cows. One of whom decided to sit down
in the middle of the pitch and had to be encouraged to continue on its lazy
stroll.

The game was also halted for the six thirty bugle and ceremonial lowering of
the national flag, this disrupted my teams brightest portion of play for
about half an hour. I wondered what Alex Ferguson might have said had he
been in charge 'Well Garth, I thought we had the upper hand until the
flipping bugle and those donkeys!' Maybe something for FIFA to consider,
nothing is beyond them.

A tough, equally fought contest that defined the term 'a blood and guts tie'
. In fact with some of the tackles flying in it is a wonder that some of
those same blood and guts were not scattered across the pitch.

It finished two-two, and in the best footballing traditions both sides felt
hard done by.

Getting your jab in first

Trying to explain to someone who has never seen a boxing match, who Henry
Cooper is didn't work that well. Explaining that, now, his main role is to
try and convince the UK population to be vaccinated against a deadly disease
(flu) met with equal bemusement - 'the government has to tell people
vaccination is a good idea? I thought you all went to school?' Fair point.

We then got onto a conversation about boxing. For someone who has only ever
seen fighting that ends with a burial this seemed about as alien as people
not wanting to be vaccinated.

'Why do they wear gloves?'

'So it doesn't hurt'

'But you just said that people can get brain damaged'

'yes they can..er..it's a strange sort of sport'

'hmmmmm'.

Being a white face seems to mean you have to have all the answers to
everything all of the time.

Those, in the UK who see vaccination, as some sort of optional extra should
come to a place like this and see the children here who are maimed and
killed by childhood illnesses such as (to pluck three at random!) measles,
mumps and rubella. The more people you vaccinate the less likely the others
are of getting sick, so everyone is a winner.

Anyway I'm getting off the point. After much logistical huffing and puffing
we finally got the equipment in place to vaccinate the clinic staff against
meningitis. Just getting to this stage was a difficult enough from an
explanation point of view 'you want to give us an injection, but we're not
sick!' 'Why will you vaccinate us, but not our children' the simple answer
is that we haven't enough vaccine, but that's not a very satisfactory answer
for anyone.

It also involved one of those GCSE maths questions that I loathed with a
passion at school. Marcus has to vaccinate 137 staff each vial will
vaccinate 50 staff. How many vials will he need? Obviously it's not exactly
degree level arithmetic, I still managed to press the wrong button on the
keyboard and went quite far down the line towards ordering four vials, until
someone pointed it out!

Anyway the appointed day arrived and I sat with a translator and a large box
of syringes under a large tree and zapped the vast majority of the staff.
Very refreshingly when one of my outreach staff was late the rest of them
feigned immense pain in their upper arms, as if I'd injected them with a
pitchfork!! Glad to see stupid schoolboy humour crosses seas and deserts
with such apparent ease.

At least we have prevented a few people from dying of a preventable disease,
but in the grand scheme we really haven't scratched the surface, or as Henry
Cooper might put it, our guard is very much down.

What Happened Next.

I seem to remember finishing the last blog with the words 'I'll write more
tomorrow'. I didn't..here's why.

The computer made a satisfied 'ping' noise as my last e-mail dispatched
itself into cyber space. A second later the satellite phone next to me
sprung into life.

"Ah, good, you're still up" (the boss, in the other base site)

"Yep, was just about to knock off to bed actually."

"Well don't, you are going to be on a plane tomorrow morning. there's a
report of cholera in one of your outreach sites on this side"

"S**t"

"And lots of it.apparently"

No sleep, spent hours packing. Kept myself alive on coffee for two days.

The previous week had been a really hectic and the most physically demanding
of my time here.

The much vaulted nutritional assessment had begun. The plane had dropped off
a senior nutritionist, to a group of very sceptical medics, in fact to be
honest we must have seemed like a group of grumpy teenagers. I think we all
expected to be told off. She had arrived to assess the childrens feeding
program and make suggestions on how to improve it.

If I'm honest I'd been dreading it. I thought she would surgically attached
to her desk who'd never so much cast eyes on a malnourished child, let alone
tried to feed one. Thankfully I was pleasantly surprised. Ellen was a
veteran of various projects and certainly no stranger to the hardships
experienced here. Though she did say it was the most basic place she'd ever
been, which I take as a sort of bizarre badge of honour.

The plan we hatched was to try and do two short visits to two outreach sites
and do a brief nutrition survey in each. It's worth giving a quick overview
of the nutritional state of this nation.

In short there just aren't fat people here. Malnourishment as we would see
it is so insipid here as to be a meaningless term. The mothers here never
attend the clinic because their children are under weight. They present
their children with the problems that are associated with it, such as
opportunistic infections.

It is hard, as a westerner, to deal with this. In the beginning I used to
internally fume (thankfully I never voiced these views!) with the parents
'How could you not see your child was thin, he's just over half the weight
he should be???!!!' But I've come to discover it is simply a matter of
perception. They haven't seen what a fat baby looks like so how would they
know what was healthy. I could leave this office and within five minutes
find a handful of children suffering from some level of malnourishment,
although it's dark now so people might ask a few questions, and I might be
arrested!

We headed out in the early morning sun for the five-hour walk to the first
outreach site. Luckily the weather was reasonable and only hit the mid
thirties, amazing what a boy from rainy Britain will put up with. Moses was
there to greet us and eagerly pointed out all the houses of the people who
he thought were hiding underweight children, armed with this information we
retired to our tents to sort out a plan of attack

We left early the next morning with the thermometer soaring into the high
forties. The first few houses yielded no children under five (our target
group). As we ducked a head into a large hut nearby we seemed to interrupt a
local conference of the villages under fives and busily set about taking
measurements. Both mothers and children greeted this with amused
bewilderment. Some wanted to be measured twice!

Onto the next cluster of huts with a notebook bulging with data.

"Hello, we are doing a survey on malnourishment, do you have any children
here" I said.

'Ahh, good' Said the nearly toothless old woman making her lunch outside "I
'm so pleased you've (she actually used the local word for foreigner) come."

"Good, so er.. Do you have any children under five?"

'No, but in that tree over there is a really big snake with eyes that shine
like torches at night, you can kill it for me"

"Er. that's not really what we've come here for"

The conversation was abruptly halted, just as it was getting interesting; by
the translator who said that he thought the woman had 'confusion from God'.
I may be from the same place as St George but reptile slaying wasn't in the
job description. We left the woman and her ferocious snake to fight it out
amongst themselves. The results of the malnourishment indicate that at
present things are reasonable but unlikely to get better and, as the wait
for rains continues, likely to become more acute, one to watch.

The second outreach site, run by the easy-going, James was, as ever, a joy.
The staff are the brightest of all four sites I see, they are eager to take
on new skills and learning. Sadly, the community they serve doesn't match
this commitment. We have been asking for help in constructing some new
buildings since late October, and still they remain unfinished. The whole
process should take a week or two at the most. It seems (to quote a
favourite phrase of my brothers) they can't be arsed.

So we decided to play hardball and call a chiefs meeting. Items on the
agenda included some health education and a chat about malnourishment as
well as the participation issue.

I wandered through the market at lunchtime and was greeted by an alarmingly
drunk man who shook my hand more, out of a need for physical support, as
much as an expression of greeting. This man was (I discovered half an hour
later at the meeting) the head chief. The meeting revolved around us trying
to reason with a man who was barely able to sit on his chair. Some of the
sub chiefs seemed interested but others just seemed to be following their
leader into alcoholic oblivion, including the head of the prison service,
and no, I've no idea why he turned up either, maybe he brought the booze!

So, in conclusion, a bit of a waste of time. I did a least get the pleasure
of watching the chief trip over and fall down a small hole just outside the
clinic as he left the clinic. With leadership like that who needs enemies.

It was soon back to the base and the late night 'cholera' phone call.

We had come back early to the base to help deal with a small outbreak there,
we were intending to stay a week. This phone call changed plans
dramatically.

In the bases there is a permanent doctor and nurse presence. Monitoring of
disease is much more rapid. The outreach clinics are run by national staff
(with support from our sporadic visits) and the only communication is a note
sent by runner. In truth an epidemic like cholera or meningitis could fester
for weeks and no one would know.

This outreach site had reported on Monday night they had a possible cholera
death and was treating a patient with suspected meningitis. We got there, by
plane, early on Tuesday morning.

First problem was to assess the patient (a fifteen year old boy) in the
clinic, with possible meningitis. I have never been so proud of the staff in
any clinic I work with. The symptoms were a little vague and it was not, a
classic set of symptoms. No blood tests, no lumbar puncture just a set of
vague signs. We would not expect that level of judgement of anyone in the
UK. But they done what it said in the book and given the patient Ceftriaxone
(the meningitis antibiotic), without any hesitation. In doing so they had
undoubtedly saved his life.

The next day we left to go and see the patients' family (a check they weren'
t all struck down with it too) Thankfully it seems an isolated case. We
moved onto the house of the man who had possibly died of cholera. He lived
in a little hut, tucked off the road, surrounded by red acacia trees. He was
a strong man; twenty-five years old (the same age as me) he had a wife and
children. A week ago he had complained of feeling unwell, had begun to vomit
and had loose stools a few times (Crucially not the right sort or volume for
cholera). After a day of this he was taken to the clinic and they had tried
to treat him with what they could and refer him to the base. He never made
it.

We sat under a tree with his wife, children, mother, father and
grandparents. As they told us about his final days the grief and pain which
they felt became obvious. They answered some very painful, difficult
questions with as much information as they could. The dignity with which
they spoke about him was humbling. I had worried there would be an element
of 'well, where on earth were you lot when we needed you?' but they simply
accepted it as part of some grand plan. I can't even pretend to say I would
have managed to view it that was so soon after the event. Profoundly moving.

In short, I haven't got a clue what killed him. But I'm as sure as I can be
it wasn't cholera. We returned to the clinic and a meeting with the village
elders with the news. A proclamation like this is a heavy burden of
responsibility.

To tell a towns elders that you don't think they have a cholera outbreak is
a very big call. Particularly a county town the size of this one. It's not
the sort of thing you can get wrong. You couch the sentiment in 'with the
information we have at the moment' and 'obviously, without seeing the
patient and doing tests we can't be sure'. But no one ever remembers those
bits. We are saying the village doesn't have cholera at the moment. Full
stop. Reputation and trust very much on the line, not an easy day.

That evening we saw our second meningitis patient. Thankfully, if all goes
as it is going at present he will recover. As we flew out from the dusty
airstrip, and back to base. I left a place will still much uncertainty. Will
the meningitis cases continue to rise? Will cholera stay away? (With the
water situation in the village the realist inside me says it's unlikely). We
shall see.

So I'm back in the base now, can of coke in hand, after a hectic few weeks
it's nice to have a few days to chill and do some paper work, and I never
thought I'd say that!