Novice to expert.

Assessment over we got into the business end of the week. Planes bringing
supplies arrived, cool boxes and syringes (in boxes!) lay everywhere. The
fridge generator grumbled and moaned over the extra work of trying to chill
more than two hundred ice packs.

Three weeks ago if you'd have asked me to organise a vaccination campaign I
would have found it about as easy as doing a newspaper crossword under
water, in Chinese. Now the only people who had ever done one before were the
driver and I. I was very much being looked to for all the answers, anyone
who knows me at all will testify that any answers on any question are often
beyond me at the best of times. The pressure was most defiantly on.

Thankfully the cavalry in the shape of a Dutch nurse arrived to help me out.
Very interestingly she had done my job here for nine months two years ago.
The more we talked the more we realised that we had been doing exactly the
same things during our time here. She had built a fence around one clinic. I
had rebuilt it. She had introduced anti natal care into the outreach sites.
I had reintroduced it. Sustainable development is a long way off I think.

Preparations made we got in the car at six thirty (or 'silly o'clock' as I
preferred to call it) and down the track went the vaccination travelling
circus.

The chief welcomed us and had arranged all the people in a queue!!!!
Obviously, coming from the UK I greeted the sight of people queuing with
utter delight and unconfined rapture, I nearly joined the end of it out of
habit. We rattled through eight hundred vaccines by lunchtime.

The way we set up a vaccination session is the same format wherever we go.
Two 'shooters' jab the people and the injections are prepared by the
imaginatively entitled (if not exactly succinct) 'meningitis vaccine
preparers', finally it's on to the tally sheet, to get a score at the end
and keep my boss happy. It's more like a factory production line than
healthcare. No time for chat and idling around, just keep them moving at all
costs. The vaccination team, when working well together run like they are
manning an artillery gun, not preventing meningitis, in this case our team
were superb.

The main problem here is that following a queue and 'move in one direction'
system (as we would know it) isn't understood by the population. We used
trees and string long lines of tape (almost identical to police cordon)
between them to try and encourage/force people to move in the right
direction, but many seemed happier to dive under the tape rather than
proceed to the tally sheet desk. I guess it's all about conditioning.

In the west since we learn to walk (and possibly before) we are used to
queuing up for things (post office, ticket booth, toilets etc etc) when you'
ve never had to queue up in that way or walk in one direction through a
series of points where you are required to do things it's not second nature.
For a while it was like herding cats! A few strategically place chiefs
helped a little.

We returned the second day for more of the same and pushed the numbers over
one thousand. Pats on the back all round.

It was onto a much bigger village and a bigger challenge the next day. In
order to get the maximum number of people possible we tied our vaccination
in with another NGO's food distribution day. This is (as the name perhaps
suggests) a designated day of the week when malnourished children and their
families get a weeks food ration. It's not exactly top-notch cuisine. In
fact it's dull and basic, but it keeps you alive.just.

People come from far and wide to the distribution, so we operated on the
'well whilst you're here, lets make sure you don't die of meningitis in the
meantime' principle. It worked well, too well. We had more than a thousand
people turn up. Crowd control became a real issue and in the end we had to
use tape on the ground and more chiefs to guide people. It wasn't wholly
successful with some chiefs seemingly unable to get people to move in the
right direction, and one, who was about as much use as an Easter egg in a
blast furnace.

By lunchtime we had vaccinated more than one and half thousand people. I had
had to abandon my job of supervising the vaccine preparers and plough into
vaccinating, opening a third line of people. This eased the pressure
slightly but people seem to be appearing from nowhere. My right arm had
performed the same action so many times repetitive strain injury almost set
in. I dreamt that night about having to throw a million darts in one hour;
otherwise crocodiles would eat me. I'm not sure the dream and the days
events were entirely unrelated, where the crocodile bit came from I'm not
sure, must be the anti-malarials.

History Repeating

'You don't need to do a meningitis assessment' the e-mail said, what a
relief, I could finally get out to do some outreach and sort out a
much-neglected clinic. Things were looking up. 'No, I think it's much better
if we just do a vaccination campaign'.

This sentence may just have well have been accompanied with the sound of a
horse, carriage and sherman tank being driven right across the plans I'd
spent a reasonable amount of time and effort sorting out. I've just
recovered from the last one, not again. Please, for the love of God no! My
head hit the keyboard meaning that the reply began 'dear
dfjrfdkvhemrfldkgj,/fdgkfqwjhkdkf;flbv,me#%. Which is probably a good thing.

The sun was just up, and still a very dark orange colour as we left. The
dirt track up to the first village was reasonably smooth, but with a few
vertebrae jangling ruts and divots. Along the way children ran from huts to
wave, the more brazen older ones made reasonable attempts to jump on the
back of the car. We managed to outrun them, but in some cases it was close

The plan for the day was to work out how we could vaccinate the three
villages that were home to our current meningitis riddled inpatients.

For those who think assessment needs to be complicated I would refer them to
our current method.

Step one - See which village the patients with meningitis come from

Step two - Visit the village

Step three - Vaccinate

In no way rocket science. But it seems to be working. We are already seeing
a real drop in cases in the first villages we vaccinated three weeks ago.
The vaccine takes two weeks to become fully protective. When I was a
slightly hard-up staff nurse I took a job giving out flu jabs to city
workers. This experience of vaccination has been altogether more challenging
but also a whole heap more rewarding.

The first village we visited already had not only a clinic but also (drum
roll) another NGO with expat staff. In many areas of the developing world
effective collaboration between different organisations is as likely as the
Pope converting to Buddhism, however in this case we actually get on very
well. I brought a few canned drinks, which helped.

Obviously there are parts of this NGO's programs and how they run things
that make me wince but I'm sure the same is true of them with us.

They don't have the sort of medical program we are able to offer, however
they have trained vaccinators coming out of their ears. Staffing issue
solved.

The chiefs in this location needed no convincing that vaccination was a good
idea. The eleven people who had been struck down with it in the month had
ensured that. They spent the next fifteen minutes criticising the NGO who
ran their clinic. All a little embarrassing, particularly since a few of
their representatives were present. I spent a long time finding a slowly
moving gecko ambling across the floor very interesting.

Anyway on to the next village, which was pretty much the first village in
microform. Easy to vaccinate, community very pleasant, no problem.

We then struck out for the third village. The road deteriorated with every
kilometre and finally evaporated into dense, low, scrubby undergrowth. The
Landover pitched and tipped down deep ditches and it was impossible not to
bang you head on the windows/seats/various other bits of the car, when I
emerged hours later I felt like I'd done a few rounds with an angry Mike
Tyson.

Finally we found a route through to the dried bed of a large river. This had
the advantage of being relatively smooth and easy to drive down it had one
major disadvantage in that it was impossible to see where we were. After
more than an hour of driving and frequent, 'lets try down here' detours we
finally arrived at the village.

A meeting with the village elders identified that they had indeed had cases,
though it was difficult to separate meningitis from other causes of death.
With the time it would take to walk to the nearest clinic of any
description, six hours, I find it pretty inconceivable that all the cases
made it to any form of health care.

There is absolutely no way of knowing how many people have had, or will have
meningitis. This village's inaccessibility makes it especially vulnerable
but it also acts as an awful catch twenty-two. The reason this village has
such a problem is it's inaccessibility, but it is this inaccessibility that
makes it, sadly almost impossible to vaccinate. The airstrip is too short to
land a plane, and the road is so poor it would break the car if we tried it
again. We also can't get there in less than three hours and the security
situation means we can't use another village as a staging post. Paranoia
about how cold we have to keep the vaccines has also reached new heights

I guess a year ago I would have thought that if you really wanted to
vaccinate an area it would be possible by some means. However just as this
area has no access to healthcare so healthcare has no access to it. We
returned back to base with the sun orange, but at the opposite horizon. A
vaccination campaign planned on the way back on the back of an envelope (I'd
forgotten my notepad). It was going to be a busy week.

The Beginning Of The End

It's three thirty in the afternoon and I'm lying on a blanket. The sun is
peaking through the leaves of the rustling tree above, book in one hand, and
Ray LaMontagne on the ipod. My return to first team action hasn't exactly
been frantic.

By the evening I'm back in clinic. A child with a fever and confusion, a
myriad of possibilities and the lab and microscopes are out of action until
we get some sun. Solar power the only option here. It will have to wait
until tomorrow, child admitted and settled. A man with a thorn deep in his
foot, an injection of local anaesthetic and a scalpel, tweezers and a few
sutures later and he's off grinning into the market. Sunday afternoon hasn't
been so leisurely in ages.

So I've sorted out my contract, which had been a little up in the air. This
whole adventure will meet its conclusion in a little over four weeks, I'll
have ten months on the clock by then. I haven't really thought about how I'm
going feel when it does all come to an end. A mixture of thoughts is a
certainty, sadness most obviously. What I do know is that I'm getting really
tired and it's time to get out before I become bitter and twisted or, more
importantly and more probable, start screwing things up!

So the plan this week (and it all changed an hour ago, so who knows whether
it will actually materialise) is to go and do some outbreak investigation in
a few villages, and then (and if this happens I might fall off my chair!)
possibly some outreach. I've been pushing really hard to get to one
particular outreach clinic, which is very much the forgotten child of the
four. It is consequently the weakest by a considerable distance. Not a huge
amount I'm going to do in a month but at least we can get things moving a
little before rainy season, which approaches with break neck speed.

I hope you all have good week. More as and when.

Fear Itself

F D Roosevelt was clearly a man way ahead of his time. In the late nineteen thirties he proclaimed that all we have to fear is fear itself (can’t see the current incumbent managing anything quite so profound). Sadly in the recent terrorist clamor this seems to have been rather lost.




In terms of your likelihood of dying at the hands of a terrorist it's one in 9.3 million. Which is roughly the same as being killed in an avalanche, no chance of that happening to me here, though a bit of snow would be most welcome! This is probably one of the few parts of the world not to have been altered by the events of September 11th and the US’s reaction to it.




However in its own way this country suffers from a similar paranoia. Recently there has been a spate of cattle raids, all pinned on one feared tribe, a few people have been killed. The local population has armed itself to the teeth in response. Recently the roof of a mud hut fell down (no one was hurt) but an old woman screamed. Someone nearby heard the screaming and presumed it was cattle raiding and opened fire. Someone else heard the screams and shooting and presumed the same and started shooting as well.



News spread round the village that there was fighting and the women and children fled into the surrounding countryside, having to be coaxed back during the course of the day. The chances of being killed by a cattle raider are very small indeed; none of my staff who I work with could name a single family member who had met their end this way. However this is inversely proportional to the panic they instill. The link between us in the west and terrorism is striking. Particularly when you look at the havoc malaria and other diseases wreak on a daily basis.




For malaria read heart diseases for cattle raiders read terrorism and the only conclusion one can draw is that we are all more than capable of irrational fear. It’s also interesting to note that in the west much is made of the media over exaggerating the menace of certain perceived threats to our health and safety (comets, bird flu, beef etc etc). Here however there isn’t any advertising and few people read newspapers and yet the problem prevails. Psychologists, sociologists and anthropologists book your tickets; your PhD subjects are just a few plane trips away.

A Much Needed Rest

We returned by car to the base site in the early evening. It was so strange being driven up the rutted dirty track to the base we normally walk down. A six hour walk became an hour long drive. Fortune had been on our side, this was about the only month we could have used a car, and used it had been, with great success. A mixture of insecurity and flooding meant that most of the year the villages are cut off to anything other than travel by foot.


The sky was a light orange colour as we crisscrossed the plains of this barren country and wound our way back to base. We drove past soldiers on drill, a water pump with maybe a hundred jerry cans lined up in a neat queue, herds of cattle and an old man playing with his grandson outside his house, the evening’s meal bubbling away in an old, battered pot on an open fire just behind them. Being in a car gives you a certain distance from life, anonymity, it was a strange way to view a country and it’s people I’ve come to appreciate hugely since last year.



A shower and an orange juice and I was fast asleep. Awoken just an hour later…”sorry mate there’s a gunshot, need you in theatre”.



Matthew was a young man who earlier that evening had been shot through the hand. Normally we would have just dressed it and organised for him to be flown off to a surgical centre for repair. In this case however the injury wasn’t so serious, just a lot of skin and muscle damage. So with a hefty dose of Ketamine we set about putting the bits of his hand back together. It took three hours. Admittedly a good fifteen minutes of this was spent hunting down a large grasshopper that was jumping round the room as if not constrained by the laws of gravity and evading all attempts to kill it.


Being a room full of blokes we suffered a complete failure to multi task and had to halt proceedings completely whilst we hunted for our errant foe. It was, however a bit too quick for us and finally escaped through a hole in the mosquito net covering the door. Back to work, hand repaired and patient left to sleep for the evening, wandering back to bed.


Two days later I was on the move again, but this time for a few days off at the missions’ base, the pace has been relentless it’s important to get your breaks when you can. The whole cliché of the work out hear being a marathon not a sprint is more true than I could ever have thought possible.


The clouds of rainy season have begun to gather again, bringing the climate to full circle. I've tried to explain to people who haven't been here long enough to experience the joys of the rains. The painful stagnation, the weeks without planes, trying to treat patients outside in driving rain. I've tried, I've failed.


It's rather like trying to explain this country and it's problems to all of you. I can give you a glimpse and hope that it makes sense but it's impossible to give you more than a vague feeling. Theres so much i'm unable to put into words.


As more and more of the people who I started with pack their bags and prepare to leave I find myself in the position of being an ‘old-hand’. It doesn’t seem very long ago that I was stepping into this madness for the first time, In some ways it doesn’t seem five minutes in other ways it seems like a lifetime.

Vaccination Situation

“How many?” The local authority leader sat back and scratched his beard. He thought for a moment. The room was silent apart from the rustle of papers. I sat on the plastic chair provided and took a swig of water. “How many days?” he said “five”, “seven thousand in five days?” He verbally regurgitated the figures, wrote something down, then stood up and wished us all the best.



Meeting over, we emerged into the glaring midday sun and into a whole heap of logistical problems. I’d promised the most senior official I’m ever likely to meet here that we would be vaccinating his community by the end of the week. Time was not really on our side. Every day brought a fresh batch of patients some with meningitis some with other things, a significant minority very sick indeed.



As walked back across town to the clinic my head was spinning. Could we really manage to vaccinate a series of villages with a group of people who had never given injections before? We were about to find out.



Whilst hurried preparations to bring in vaccines were made the satellite phone was never out of someone’s hand. The clinic and its staff continued on. We passed an unhappy milestone of seeing more patients than the base site, who have a permanent doctor and two nurses stationed there. This was like nothing I’ve ever experienced.



The best ways to describe how to care for vaccines to put them in the same bracket as vintage bottles of wine or champion race horses. Basically they have to be kept at a constant temperature and not roughed up in anyway. They become like an extra member of the team. Cosseted from the harsh environment by large industrial cool boxes, in the business we call it ‘cold chain management’ or how to keep vaccines at optimal temperature, always. The cool boxes were filled with vaccines and ice packs every morning, a miniature glass vial army arranged in row.



How do you run a refrigerator in a place with no electricity? You don’t. The vaccines were driven for an hour from the base site in the morning and brought back there in the evening. The word palaver doesn’t come close.



As we got up in the morning instead of “how are you?” it was more a case of “how are the vaccines? The level of care given to the cool boxes approached the level of some of our sicker patients, paranoia set in. The cool box temperature started to rise and worried faces abound whilst we tried to reorganise ice packs and move the cool boxes into the shade. If the vaccines were spoilt by the heat the whole thing would be for nothing. And this isn’t the sort of place where a fridge engineer can pop over and help out.



By this time, thankfully, the team had swelled to four. My outreach buddy had returned and there was extra medical help as well. However the main burden of the workload was given over to the guys we had just employed to vaccinate.



In essence we grabbed people off the street and told them that after a mornings training they would be the spearhead of a mass vaccination campaign. The simplest way for this to work was to give everyone only one job. The consequence of this is that you have an enormous number of staff to organise. Everyone from vaccine preparers to crowd controllers to child limb supervisors needed to be instructed. What on earth does a child limb supervisor do? I hear you ask.



The problem here is that it is difficult to get the mothers of children to hold them still. Culturally it seems it is not a done thing. In previous campaigns children have run away mid-injection, with syringe still dangling from buttock, like a porcupine. That wasn’t going to happen this time, not with a child limb supervisor in the team at any rate. This womans’ job was to grab errant children and restrict all unwanted movement. This female became the most feared woman to the villages under fives. In appearance she could best be described as robust.



After a day of training, our new staff were instructed to be ready for eight the next morning.



D-Day arrived. I sat on the airstrip watching the sun come up, cup of tea in hand, ipod on. The only five minutes of the day I got to myself, this day would define the whole campaign, if it went well the momentum would build. If it didn’t the campaign would be over before we had started. In the distance I could hear the megaphone of the local authorities informing the village that today was the day for meningitis immunisations.



Took a last swig of tea, headed over to one of the two vaccination sites. Already a long queue of people was standing around the tent. Seven exhausting hours later more than one thousand people had been vaccinated. Result! Much better than we had hoped for, the main takers were mothers and children.



The young men of the village didn’t seem to see the need. I guess when you carry an AK-47 wherever you go you don’t think something like meningitis will kill you. A twenty year old man tragically disproved that point later that evening.



For a week the pattern was the same and by the end 7758 people had been vaccinated. I had the ‘honour’ of giving the last injection. The child seemed not to even notice. They build them tough out here, they have to, it’s a very harsh place to try and grow up.

The Ides of March

In my previous incarnation as an accident and emergency nurse I came to
dread the month of March. For reasons no one has ever properly explained to
me the department saw huge rises in the number of patients in this month.
All sorts of possible explanations were given as to why this was, all I knew
was that, at times the place resembled Dante's inferno, on a particularly
bad day.

Anyway, no one had warned me that the inevitable switch from sensible
February to mad March could plunge the project to levels of chaos and
disorder not seen since some of my GCSE coursework.

Things had started reasonably well. I returned from a nice break and hung
out in the TB program for a while, which was very chilled out indeed. Later
that week there had been a plan to do some outreach and see the guys in one
of the clinics for some much needed training and support.

There is a famous military saying that no plan survives first contact with
the enemy. This plan didn't even have time to put its boots on.

The dust swirled around the plane as the propeller whirred. As I stood on
the airstrip, having just disembarked I pulled my hat over my face and
crouched down to try and shield myself from the biting sand. The propeller
stopped, the sand and grit did not. We had landed into the middle of a
sandstorm. It lasted only a few moments but everything was covered in a fine
film of grit.

We had received a letter from the health worker that he had had a huge
increase in the cases of meningitis in the clinic. Another clinic had
reported that people had started pitching up from a village half way between
the two. Four people had died already, and sadly that number was to
quadruple before the end on the fortnight.

With me was not my usual outreach buddy (away doing a similar assessment
somewhere else) but a nurse from Denmark, Anne, with loads of experience in
this kind of misadventure and, being Scandinavian, impeccable English.

We landed at around lunchtime and, after throwing the tents down, we headed
into the clinic. We didn't leave until just past midnight. Enough critically
ill people to fill an average western intensive care unit, and all requiring
just that level of care, had it been available. It wasn't, the nearest they
had was me and another nurse and a group of utterly exhausted clinic staff.

We ran out of space in the huts and had to get one of the guards to drive
wooden posts into the rock hard ground outside so that we would have
something to hang the IV drips on. At sunset I looked out across the clinic.
A few small fires were burning as caretakers tried to sort an evening meal
for the patients. It was surreally peaceful.

I fell into the tent and slept with clothes shoes still in situ and
stethoscope round my neck. To be woken a few times during the night to sort
out various drips and, sadly, to confirm that another family had lost one of
its members.

The next day we organised a meeting of the chiefs. Well, if I'm being
strictly accurate, we gate crashed one that was already going on. As we sat
under the tree they told us their people were dying, we asked them to show
us where.

So the next morning I found myself walking out to an outlying village with
not only a chief but also a bulging medical bag and absolutely no idea what
we would find. The chief pointed, with a long stick he carried, to a hut.
'Two children are very sick in there' he said.

It was dark inside the hut. Shadows moved around in the dim light as my eyes
struggled to readjust to the sudden change from the glaring brightness of
outside. As I looked down there was the wizened face of an old woman (the
grandmother) kneeling over the lifeless bodies of two children. The younger
was three, the older eight. Without any further examination it was clear
what had happened.. meningitis. We carried the children outside and placed
them under a tree. Both were contorted with heads thrust back, rigid and
feverish, they were gurgling very ominously. We administered strong
antibiotics and organised for the chief to take them to the clinic.

My heart was now racing, how many more would there be in this village?
Thankfully the answer was none. After a few more hours of walking round the
village we returned to the clinic. The drama of the day wasn't over however.

It was about ten o'clock that evening, I had just managed a few spoonfuls of
pasta when one of the clinic staff appeared at the gate. There is a very
sick baby you have to see. I walked/trudged over to the clinic. The child
had a nasty case of pneumonia so I set about sorting out some antibiotics.
As I was sitting in the pharmacy a few shots rang out, reasonably close.
This is a fairly frequent occurrence here, mainly a result of a very heavily
armed population.

As I waked across from the pharmacy to where the child was sitting a few
more shots. All seemed to be aimed skywards. Very quickly after that a lot
more shooting, and this was not going into the air. Perhaps thirty seconds
later what can best be described as bursts of very loud, very close, machine
gun fire pierced the cool night air. At this point I abandoned my 'how to
give your child antibiotics' chat and opted instead to lie on the ground and
crawl, very slowly, to the relative safety of one of the huts. Five minutes
doesn't seem a very long time, I can assure any reader when there are very
hot bits of metal fizzing over your head it seems like an eternity.

After leaving a healthy fifteen minutes from the last shot I emerged from
the hut and looked for Anne. Thankfully she was fine and had much the same
experience as me, spending a good half an hour lying on the floor of the
kitchen. We opted to stay put and not try and walk to the other clinic or
back to base, often the worst things to do in these situations is to move
around drawing attention to yourself.

In the morning it was as if nothing had happened. Apparently the bullets had
been expended in the quest for the meat of a hyena. I'm yet to be convinced.
Not a single shot heard for the rest of the week. Maybe they had used up
that weeks ration.

The next evening I did what any sane mid twenties bloke would do, and rung
my mother. 'Keep your head down' was her sound advice. Obviously working in
an area of conflict these things are occasionally going to happen. However
not one of us, here or in the west, can wake up in the morning and say we
will see the evening with an absolute certainty. I could be in places much
more dangerous and the crucial difference here is that I'm not a target; I
can't say that of the place I call home, London.

And what of the two children with meningitis we had found in the village?
After a week of convulsions, antibiotics, and crossed fingers both children
walked home. In terms of a justification for being here, no more reason
needed. Next blog.....Vaccination.

Happy Easter all