All that you can't leave behind

The title for this blog is a line in a U2 song that's been in my head for a while, and I think it pretty much sums up life for me at the moment.

My flight to the missions’ base was uneventful. After a day of debriefing I was on boarding another plane down towards the coast. I stepped aboard and slumped down in my chair. In many ways the town where the missions’ headquarters is based is functional, but any life or soul has been removed surgically. I was pleased not to be going back.

A man appeared at the front of the plane with an envelope. ‘Ladies and Gentlemen’ he said ‘It’s time for our prize raffle, madam please pick a number’ he motioned to the envelope, the woman at the front obliged. ‘Ticket number, six seven five’ he bellowed above the roar of the engines, which were staring up. I half choked on my bottle of water ‘that’s me!’ I said. ‘Wonderful! Congratulations!!, you’ve won our top prize!!!’ He said almost exploding with excitement. ‘You’ve won, your return flight here… (He paused for drama) for only forty dollars!!

‘I’ve won a flight back here again?’ I said, trying really hard not to sound like I’d just won a break away holiday to Guantanamo Bay. ‘Yes!!’ He screamed almost convulsing with delight ‘we haven’t had a winner all week, I’m so pleased’ he said. I tried to imitate is joyfulness, but was too tired to muster much of an effort.

I stepped off the plane, still a little befuddled and in need of food and sleep. The only planes I have to fly on now are huge Boeings and Airbuses. There’s things about the planes that have (as one of my friends put it) ‘a touch of the Buddy Hollies about them’, that I’ll miss, bizarre raffles aren’t included.

Now I’m sat in an internet cafe, next to a beach in East Africa. The water is turquoise, the sand is white, a more tranquil scene it is hard to imagine. It’s a world away from where I've been, and a world away from where I’m going, London apparently having swapped spring for autumn.
It’s off season here, so there is no-one around save a whole bunch of worn out NGO workers. It’s really amusing, every aid angency you’ve ever heard of, and some you haven’t, are represented here in the form of horizontal, sleeping aid workers.

Attempting to sum up the last ten months is going to be impossible, so I’m not going to even try. What I’ll do is scribble a final bit when I’m home early next week. Have a great weekend all.

Exit

It’s difficult to adequately describe the last few days of my time here. The first emotion, fairly obviously, is one of sadness. But I also had a fairly rapidly approaching realisation that it was time to go. There is still so much to do here, but that is up to someone else.

My final day began, as many days did here, by being woken by the six thirty bugle call and ceremonial raising of the flag. The bugler has improved since I’ve been here, but he still sounds often like he’s drowning a box full of cats. I won't miss his music one bit.

I sat outside sipping a cup of tea, as the sun rose above the trees. One of the clinic staff came over, a patient to see. I wandered over to the clinic.

The woman was lying on the floor; she was rolling around in the sand, hyperventilating. Hysteria is a very common problem here. All sorts of theories abound as to why this is. Basically my view is that the women here have incredibly stressful lives and as the only method of escape is sickness they pretend to convulse as a method of getting some much needed time off.

It’s still a little difficult to treat and often we have to just leave them alone until they calm down. In this case I sent the family away for ten minutes and sat with a translator. I told the woman I would tell her family to give her some days of rest if she stopped throwing herself around. She did, I went back to my tea, which was still warm.

The previous night had been my leaving do, and as I went back to the expat area various people were emerging from their huts. We all sat down for breakfast together.

I walked round the market, to say a final goodbye to the village. I met up with various chiefs, sub-chiefs and, bizarrely, the head of the prison service. They wished me good luck, ‘go in peace‘was a common sentiment.

My farewells were cut short by the roar of the plane overhead. A few more hurried goodbyes and then that was it. As brutally as it had begun the ground was disappearing away from under me and life as I had known it for the last ten months was over.

As might be clear from the writing, I may have physically left, but my mind is very much still there.

The plan for the next week is a beach and then home. I’ll write a few final blog instalments early next week.

Full Circle

It's four in the morning, I'm crouched in the dirt, outside, the child at my
feet has a fever and pneumonia, the only light, on a cloudy night, is my
rapidly fading head torch. My spirits are heading in a similar direction. It
's raining, by the bucket.

I draw up some antibiotics, have a quick chat to the mother and usher the
pair inside a hut. Being on outreach is a hugely liberating experience. It
is also very lonely. I'm the most qualified person for five hours walk in
any direction. My outreach buddy has never worked with sick children. If you
are a poorly paediatric in the neck of woods where I am, I'm pretty much it.
Poor souls.

The child doesn't look good; he has a pneumonia brought on by measles. I've
watched two children die of measles this week. If I get called again to see
this child tonight I think the only useful thing I could bring would be a
shovel. I trudge back to bed.

In the morning I return. The child is a little better, the fever is down,
but his chest still sounds like the noise the sea makes as it washes over
shingle. I let the mother listen to my breathing through my stethoscope and
then his, as a comparison. I can see in her eyes she knows it's looking
dire. The childs eyes are open slightly but he is burning every last drop of
energy just breathing. I try to help by positioning him upright to help his
breathing. Every sinew is straining just to keep gasping.

A queue of patients has begun to arrive at the clinic. I step out of the hut
and have a quick 'eyeball' a couple of sickly looking old women get a nudge
to the front of the queue. The health worker begins his consultations. My
outreach buddy is bobbing around sorting out the repair of the fence. I take
five minutes to sit in a quiet corner and take it all in. There are many
areas of improvement that could be made in this place, more staff, more
buildings and a better way of getting the patients to queue. But in honesty,
I could spend a lifetime in this one clinic and not get the patients to form
a line. On this I accept defeat, utterly.

Having said that, it is running better than it was before, and it is in good
shape for rainy season, when supervision dips significantly. I've just one
more outreach clinic to say farewell to. The four days I'm spending in this
clinic will fly by.

It's four days later. The days did indeed fly by. We walk off into the
scrub, the sun already hot at seven thirty in the morning. The staff wave
goodbye, along with the mother of the sick child. Her, rapidly improving,
son sat at her feet.

What would turn out to be my last outreach walk was uneventful. The fields
are busy with people hastily planting their crops, by hand. There is not so
much as plough in sight. Towards the end of the walk we reach the outskirts
of a village and slosh into our first ankle high mud for six months. I
remark that this is like rainy season lite. At this sample of what rainy
season can be like my outreach buddy (who has only seen dry season) asks a
number of very practical questions. The old 'do you take your shoes off to
wade through rivers' debate rears it's ugly head for the first time in a
while. There is no right answer. Personal preference determines what you do.
For me it's shoes on all the way, but these things you have to find out for
yourself. I try to explain what rainy season is like, but it's impossible.
It's like trying to explain what snow is to the guys here. Unless you've
been there you can't really imagine.

We are soon at our destination. Cup of tea boiling, rain rolling in, in
terms of climate I could have been transported back ten months to the first
outreach visit I ever made, to the same clinic. The only difference is that
the peculiarities and quirks of this country and its people now seem
perfectly rational to me. Ten months ago they certainly didn't.

We sit with the staff; give half of them time off to go planting and I tell
them I'm leaving. They seem genuinely saddened by this. We laugh about the
times we have spent together. Some of the more amusing moments, the sky is a
lovely orange. The distant crackle of gunfire, thankfully a one off burst,
is a reminder of reality here. I can't quite relax, but it's the nearest I'
ve managed since being here.

It's wrong to have favourites but I do. This was the first clinic I came to,
less than twenty-four hours after my arrival and it remains the one I like
the best. The staff are eager, a joy to work with and, perhaps most
importantly, a good laugh. I hope life deals them all a half decent deck of
cards for the remainder.

We give the health worker some much-needed holiday and we share the
consultations for four days. It's not particularly busy and I'm able to do
some health education, childcare tips and health and hygiene tips. All
really basic, all really necessary. My 'how to clean your baby' chat draws a
crowd. The bulk of the work is malnourished kids. Their bones protruding
from hip to clavicle. Like a legion of miniature old men, their heads, out
of proportion and losing hair, their legs thin and bandy. The sound of a
malnourished child crying never leaves you.

Day two of clinic over, food distributed, a few, very minor staff issues
sorted it's off to bed. I'm not sure when I'll next sleep in a tent. I won't
be for a while, at least I hope so.

During the night I'm woken by a drunken man who tells me his wife has been
bitten by a snake and will die. I ask him where his wife is. At home is the
reply. I advise him to go and get her, as I can't go traipsing round the
countryside in the middle of the night. She arrives an hour (as luck would
have it just as I've nodded off again) walking. Clearly not just about to
meet her maker. I can see the fang marks but it all looks okay. Off home
again with antibiotics, painkillers and a bit of a chat about the fact that
people who are about to die don't tend to be able to walk.

Sadly during the night my outreach buddy is felled by the same bug that gets
us all at some point. She wears a groove in the ground between her tent and
the latrine. The next morning we have a short staff meeting and the car
arrives to drive us back to base. So my outreach adventure ends as it
begins. Differently to how I would have expected. But then again, to start
sticking to plans after all this time would seem out of keeping.

In the base, having the mother of all tidy ups. One day left.

Mind The Gap.

"When I see those poor people in Africa I just want to cry, I mean I'd love
to be that skinny, but without all the flies and death and stuff"- Mariah
Carey (Pop star and, clearly, deep thinker).

For those of us amidst all 'the flies and death and stuff' it has been a
busy week. The harvest in October was poor. I remember at the time everyone
told us it was poor, the problem is that this country has relied on food aid
for so long it is difficult to take predictions like this seriously. The
more wise (and possibly cynical) of our number have pointed out that, EVERY
harvest season is met with the same predictions from the tribal leaders, in
a (many would argue, not unreasonable) effort to boost the amount of food
dropped out of planes.

However, this harvest (which was in October) turns out to have been, what
the tabloid press would call, a bit of a shocker. The rains went on too long
and the crops were destroyed by an extraordinarily high number of birds
(no-one has provided a rational explanation as to why this was). Good
old-fashioned drizzle and a hefty dose of fighting earlier this year didn't
help either. We are now; in what is called in aid worker speak 'hunger-gap'.
This, as perhaps the name suggests, is when the food from the October
harvest runs out and the food that has been planted this year isn't ready
for consumption.

It also can't come as huge surprise, when I tell you that the first people
to suffer when the food starts running out are the kids. We run a feeding
program in our outreach clinics, which has seen a near quadrupling in
numbers in a month. In the base sites it's worse. Eighty children, all very
malnourished, and a program stretched to try and feed them, and this will go
on for months.

The workers in our clinics assess the children with complicated weight and
height measurements and give them a percentage against an internationally
agreed figure of what a child, in Africa, of that age and height should
weigh. Many just scrape in at half of their ideal weight. When the child has
reached eighty per cent of what they should be, they are discharged.

Feeding children sounds easy. Bring food, give to malnourished children, and
go home. Sadly life is rarely that simple. For example, as discussed before,
parents here don't bring their children to the clinic because they worry
about their weight. They bring them because of the associated with
malnutrition, namely coughs, diarrhoea etc. So if they didn't know they were
malnourished in the first place, it's pretty hard to convince them to keep
coming back to the clinic to collect supplementary food when they have no
concept of when their children are better. Hence they come sporadically and
in many cases don't come when there are other problems at home, such as
other children being sick, having crops to plant. . I did remark that we
should scrap the whole idea of discharge criteria and just have the sentence
'the child is discharged when the mother thinks they are better.'

This sounds heartless to a western reader, but when you have a whole family
to support one sick child sometimes has to take a back seat

There is also the problem of misuse, the food can end up feeding the whole
family, poorly, or worse, ends up on the market. Consequently the sickest
children are admitted to the program and are fed for a few weeks, put on a
bit of weight, are then taken home, only to lose the weight again and end up
back in the feeding program. It becomes a depressingly never-ending cycle.

During the liberation of Netherlands in the Second World War, there was and
area that was left without food for six weeks. Nutritionists were able to
show that after only six weeks of hunger women were more likely to miscarry,
infant development and future academic achievement was severely hampered. In
short, just a six-week break in food supply can have far reaching
ramifications. Here malnutrition has been going on for generations, if you
follow the argument the damage here must be thousands of times worse. 'When
I see those poor people in Africa, I just want to cry'. So do I Mariah, so
do I.

Here Comes The Rain Again.

As a UK native I am genetically programmed to talk about the weather, with
almost religious zeal. Like queuing in an orderly fashion and selling arms,
talking about the weather is what we in Britain do best. So, here goes.

It had been hot, very hot until the last few weeks. Slowly and without a lot
of warning, thick bubbling clouds began to appear on the edges of the
horizon. Huge columns of dark vapour hung in the air, menacing. On Monday it
was exceptionally hot, the heat building to a crescendo during lunchtime
until finally, at around four o'clock, mother nature flicked a switch and
unleashed a storm like I have never seen (and this from a bloke who has
spent many a summer in Ireland!). The rain fell by the gallon as fork
lightening and rumbling thunder rolled across the sky. The soil here has all
the absorbency of Lego and the water worked its way into natural divots
before wearing very large grooves in the ground.

Afterwards the village was complete mess. Most of the huts had been
constructed this year and had not been given the full rainy season acid
test. It was clear from the buckled roofs and walls that many had
spectacularly failed. The next few days were spent making hasty repairs.
Most of these repairs themselves needed repairs after a similarly vicious
squall on Thursday.

Anyway life at the clinic continued. We are currently preparing for my
'final' farewell tour; it has been a bit of a long goodbye. Six different
locations to visit and say 'cheery o' to so I'm starting to feel like one of
those ageing rock stars stuck on their nineteenth farewell tour.

The days spent in the clinic are ticking over nicely. We are waiting for the
road to dry up so we can transport timber and other logistical supplies to
try and patch up the clinic before heavy rain becomes and frequent rather
and infrequent visitor.

In many ways the clinical stuff is what keeps me going at times of
stagnation like this. We have had one child this week that was seen by me in
an outreach site. He was clearly gravely ill and it was the sort of case
that could have been diagnosed by the brownies. The child had meningitis,
pneumonia, malaria and tetanus. I hit him with every drug I had at my
disposal that I thought might do some good and told the mother to take him
to the base site. She didn't. I assumed the child had died on the way.

I returned to the base site with no news on where the child was. It was dark
and late at night when the clinics guard came to get me from my tent. The
rain was pouring down; all that my head torch could make out were the
thousands of dazzling, raindrops falling in front of me. 'Come, come' he
said. The rain moved up a few gears to the one labelled 'torrential'

We trudged through the mud along the path up to the clinic. And there,
crouched and soaked in the corner of the hut was the child and mother. There
had been a security problem along the road from the outreach clinic so she
had had to detour hugely.

The child was still alive, but there wasn't much in it. I called for back up
(the base doctor) and set about trying to sort out the patient. Again a
plethora of antibiotics and tetanus treatment was soon being sought. As I
hunted round the pitch-black medical store looking for boxes the doctor was
in the process of trying to resuscitate the child whose heart had just
stopped beating. The rain on the tin roof was so loud, despite being only a
few feet away I couldn't hear him calling for me.

Thankfully, miraculously, after a big slug of adrenaline the child returned
to healthy sinus rhythm but remained deeply unconscious. To say the
situation was bleak would be the understatement of the year, dire I think is
a more apt description. Four diseases all of which had the capability to
kill him, and he continued to fight them all throughout the days and nights
that followed. Ever day I left the clinic convinced the next time I'd see
him would be to break terrible news.

Yesterday he walked and giggled as we blew bubbles over his head. I wish
every case ended this way, but I guess if they did, then kids like this
wouldn't seem so special.

Five Things I Will Miss…. Five things I Won’t.

As time here draws rapidly to a conclusion I've been doing a lot of 'lasts'.
I've already said farewell to two outreach sites and in less than
forty-eight hours I will wave goodbye to one of the bases. Half of my job
effectively will be over. So I've turned a little introspective and thought
about what I will really miss and what I will, frankly, glad to see the back
of. So here, in an ever so, Sunday night Channel 4 kind of a way are my top
five of each. In no particular order, I'll end positive so start negative.

Things I won't miss….

1) Guns – This is a country supposed to be grabbing the opportunity of peace
with both hands, sadly the young men here seem much more willing to grab
their AK-47's and use the to lethal effect. We in the 'developed' world
should hang our heads in shame that we allowed such an enormous quantity of
armaments to flood this place, and have done nothing really to stem the
steady flow for decades. The results are clear everyday with the men women
and children I've seen killed and maimed, many by being shot accidentally.
It's such a waste of human life, and we should do so much more to stop it.
You can give me all that stuff about arms manufacture being really important
for the creation of jobs in the UK, but lining the walls of all our schools
with asbestos would create jobs, it's still not the right thing to do, is
it.

2) Villages with no access to water- I think this became a bit of a mantra
at some point around December I reckoned you'd probably all got bored so I
stopped writing about it. The problem hasn't gone away. In fact converting
our arms factories into water pump manufactures would kill two birds
...there's a plan

3) Statistics- can't stand maths, hate calculators. To be able to get
Microsoft Excel to do anything vaguely useful requires a brain the size of a
planet and a PhD in nerdology. Days of my life writing reports that no one
ever reads anyway. Dull dull dull dull dull dull dull.

4) Watching people die of preventable illnesses- It's pretty hard watching
people die at the best of times, it is almost unbearable when they die of
things that are preventable and curable in the west. In my opinion it is the
worst aspect of coming from a first world to a third world country. You know
what you could do if only you had the equipment, or drugs. I've lost count
of the number of times I've wished for a ventilator to fall from the sky, or
even just that parent's had been given the education to know when their
children were sick and bring them to the clinic sooner. And most of the time
it's really simple stuff.

5) The office politics- It's funny that if you ask most people what the
worst part of their job is they'll say, "oh, God the politics!" So, if this
is the case, why does it exist? I guess because we are all human, but it's
taken a super human effort to stay out of it, thankfully, by and large I've
managed it.

Things I will…

1) Discharging cured patients- nothing more satisfying in the world,
full stop end of line, paragraph and book. Watching a child who was close to
death running with his siblings around the clinic and then running into the
family in the market months later bright eyed and bushy tailed as if nothing
had happened has made any of the points listed above pale into the
background.

2) The walks to the clinics – with the recent dry weather and the use of
the car I've come to appreciate just how interesting the walking is. I've
been through villages that haven't changed greatly for hundreds of years,
and I've certainly been one of the first white faces ever to meet the people
who live there in their own homes. A truly once in a lifetime experience

3) The people I've worked with - Both local and international staff have
been truly inspirational, if I have given to them a tenth of what they have
given to me then I will be very happy.

4) Walks along the airstrip at sundown – Yes I know completely soppy,
but it is time for me, the only part of my day when I'm completely off duty,
it only takes about ten minutes but it really has kept me sane. And no place
does sunsets like Africa.

5) This! Writing this blog has been a wonderfully cathartic experience. But I'm
really not sure I'll have quite the same sort of material to write about in
the UK. I'm so pleased so many people from across the world have taken the
time to read it. If I have provided even a glimmer of what life is like in
this corner of the globe then it has been very much mission accomplished.

Would You Ask That Man To Stop Driving His Motorbike Through The Clinic?

I used this sentence as a title partly because it is a little eye catching
and partly because it forms part of a list I'm compiling entitled 'Things I'
ve said that seem perfectly normal here, but would seem crazy anywhere else'
Other notables include 'just come and hypnotise this chicken whilst I tie it
to the gas bottle', 'For how many days did you put the piece of cow bone in
the childs ear before coming to see us?' and 'It's really very simple, put
the gun down and THEN come into the clinic.'

So this week was a trip to a much-neglected clinic. So neglected in fact
that this was only my third visit in nine months. In many ways we have
failed them. There have been some fairly large extenuating circumstances,
the meningitis outbreak predominantly, but it still doesn't feel very good.
That the clinic is operating at all is miraculous however the lack of
supervision is evident here more than anywhere.

The drugs were being given out a little like party bags at the end of a
childrens party (i.e. everybody gets one) and the first morning we were
there we had to sack one of the staff for being drunk. It was a shame in
many ways as you are not only sacking an individual but also making life
much more difficult for his wife and children. But you can't really think
about that, after all drunk workers are not exactly good for patient safety.
Not a good start. It was to get worse.

In the afternoon I was sitting with the health worker in the consultation
room. In came an old woman with a basket. In the basket was a five-week old
baby wrapped in a blanket, I instinctively reached into the basket and
picked the baby up. The child was cold and dead. The grandmother said she
thought the child had died an hour or so ago but she had brought him in
anyway because she had heard we could bring people back to life. I think
this gives some indication of the general publics perception of what we can
do. I have to admit I was a little lost for words.

I stepped outside into the dazzling afternoon sun, it was still hot, but
dark clouds were gathering at the edge of the horizon. Dark clouds were soon
gathering in my head, my outreach buddy beckoned me over to the waiting
area. "Mate, I think this kid's got measles."

It's pretty difficult to describe how I felt; measles (thankfully now very
rare in the west) is still a huge problem here. One in every 250 cases is
fatal. If you score enough cases in a small village, (and 'enough' can be
less than twenty) you have to vaccinate.

I went through a bit of a cycle of thoughts. Firstly I tried to deny it "It
can't be, the rash isn't".this thought juddered to a halt as I found a
koplick spot (definitive proof it was measles) in the childs mouth. "Ok, ok
fine, perhaps it's an isolated case" I said glancing at the other children
around, and my eye being caught by one with puffy eyes and a very
distinctive rash. The faint sound of straws being clutched could be heard,
so I shut up.

As the week progressed we found progressively more and more cases. Most hadn
't come to the clinic at all and were merrily sitting at home. We went out
to a few of the surrounding villages and found more measles riddled infants
including one very sick child who hadn't been to the clinic and was in sight
of the health centres gate. The long and wordy public health books label
this sort of thing health seeking behaviour or (in intelligible English) why
sick people don't come to the clinics.

When I first arrived here I got the impression that people here were
actually very good at getting help if they were sick. People even seemed to
come when they weren't sick. The high numbers of patients pitching up with
nothing more lethal than a snotty nose seemed to support this theory.
However as time has gone on I've come to realise that actually we only
really scratch the surface.

If you were where I am now we could stand on the airstrip and look out at
the hundreds of huts and settlements across the flat savannah and I couldn't
tell you if the people living there were alive and well or all dying of
measles, meningitis or anything else.

So a week of measles investigation and general support ended with the
appointment of two new staff (always nice) and a vigorous game of football
on the airstrip. The plan was to return to base, pick up the stuff for
vaccination, come back out again and vaccinate. I was dreading it. The
logistical problems, keeping the vaccines cold, long days and nights and the
associated stress was not high on my wish list. Been there, seen that, very
much got the t-shirt.

On return to base we sat down and had a team meeting with all the staff from
the base. One of the nurses in the base said she had never done a
vaccination campaign and would love to come along too; objections were
raised about medical cover in the base. "You could always replace me???" I
offered, I tried (and probably failed) to make it sound like I was doing
them a favour, but in honesty, I think it was the other way around. So at
silly o'clock in the morning I watched as they bounced off along a dirt
track. I got to sit in clinic all morning and actually see some
patients.joyous!

I feel very much on the home stretch, a bit like a marathon runner rounding
the last corner, the end is in sight (two weekends left!) but there is still
work to do before I get there. In many ways I'm trying to pace out the last
few weeks. Increasingly I'm referring decisions about how the clinics are
running and focusing much more on the clinical stuff, which is the bit I
enjoy the most. The long and tedious human resource, logistical and program
planning problems aren't going to be solved in one visit and that's the most
I have to any of my outreach sites. Last week I said goodbye to two clinics
and their staff and this week I say goodbye to one of the two base sites.

At the first clinic I said my farewells to one of the staff said "I am very
happy, because you were there when there were many problems and things were
bad (the clinic was looted and destroyed and I was newly arrived for the
reopening) and now you have seen the clinic when it is good." I couldn't put
it more eloquently than that.