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!

These Boots Are Made For Walking

And thats just what they'll do. And one of these days these boots are going
to walk...er...somewhere near a place that has power and a computer!?????!!!

I've not been near a computer in weeks and when I have the e-mail has been
so slow I considered carrier pigeon. Hence it's been such a long time since
I've written, sorry one and all. I hope some of you are still checking this
site, more to follow promise.

"You must be kidding!"

"No way, rubbish, I've never heard that before"

"No, no he might be right"

"Right that's it we are going to buy one tomorrow and see if it works"

Barely twenty-four hours after this conversation I found myself knelt on the
ground drawing a straight line in the sand. Resting at the start of my line
was a beak. The beak was attached to a chicken. And it was hypnotised.

We had arrived at this particular outreach site with not just the usual
suspects. (i.e. me and another poor soul) but also a medical co-ordinator
and a logistician. A huge team by outreach standards.

In honesty, and for reasons so oft repeated it's boring, we had not visited
this clinic (nor the clinic we moved on to) often enough. It wasn't that
they were doing badly but they were (as an NHS manager might put it) 'in
need of input'. More of this later, back to the chicken.

Sitting round a camp fire (containing large amounts of out rubbish that I'd
forgotten to burn the last time!! Whoops!) That night we got into a
discussion about hypnotism and naturally (work with me here) the
conversation moved on to whether it was possible to place animals under
hypnosis. One of our number suggested the method and the following night we
performed a controlled test, of sorts. And it works!!!! For those of you
with access to chicken, and perhaps it's best if you chose a reasonably
docile one, please feel free to conduct a similar experiment along the
following lines.

Take one chicken, lie it on the ground and point it's head to the floor. If
another person slowly draws a line in the sand with their finger in a line
from the beak, about two feet, outwards, the chicken should remain
motionless…indefinitely!!!

Pushing back the knowledge of an outreach team one night, awesome casserole
the next. We had brought the chicken to late to eat that night and were not
overly thrilled with the prospect of the thing squawking for hours. So this
did have a practical purpose too. Not a peep, all night.

Things were going relatively well clinic wise. The contracts were signed
with only one amusing question.

Marcus: So your contracted hours are 40

Staff Member: What …… a day????

Marcus: Err… no…(Completely thrown by this question) a month. …Err. I mean
week. Sorry did you just say a day?

This story would be slightly less worrying had this question not come from
the man in charge of counting the stock!!!

It had been decided to make this town the new county town, what was wrong
with the last one hasn't been properly explained to me. Anyway, the town was
awash with people building and busying themselves. Hundreds of young men
have moved in to work for the various offices of local government, making
the town almost completely young and male. I'm not sure the long-standing
inhabitants quite know what has hit them.

Within a week we had fixed a fence and been able to do some very rudimentary
training with the staff. Often the process involves high amounts of damage
limitation. It's almost about making sure the staff do no harm and then
getting them to do things well. Having said that people like the wound
dresser continue to improve.

Another success was the lady we employ to give the first dose of the
medicine to the children. In many cases (unlike the UK where children are
brought up on a diet of antibiotics) this is the first time the children
will have taken any type of medicine and the mothers are understandably
clueless about the best method of administration.

On previous visits I'd observed out medicine lady using a combination of
face grabbing and overwhelming force. Rather like a patient with aggressive
psychosis the children would be pinned to the ground by an army of mothers
and bystanders. Arms and legs flailing, medicine spat and crying as if limbs
were being pulled off. The whole spectacle resembled a horror film.

This led to some very big questions from my bosses about why it was that our
clinics were using double the number of drugs they should have been. With
the number of children this lady made vomit I'm surprised the number was so
low!

Changing the behaviour has been long and laborious. Starting with, O.K. lets
sit the child up and THEN grab his face to finally, on this visit, lets get
the child to take it off a spoon calmly. I'm sure on occasion the urge to do
things the old way is still strong, and I've no idea what they do when we
are not there. But at least I've tried!

Onto the next clinic. This very calm and tranquil little village had had the
impressive joy of having a borehole and water pump fitted the month before.
This great news had turned very sour as the pump had spluttered water for a
whole day and then produced nothing more impressive than sand and sludge.

A team of engineers were on site when we arrived, swelling our numbers to
seven. Sadly the pump needed a very specific part, and had probably been dug
in the wrong place anyway… so the wait for clean water in this area goes on…

A very very very hot walk in six hours of baking sun back to base. The
temperature was fifty degrees for two hours of the walk. It was also across
open country so shade was limited indeed. All not much fun. Walked into base
with more than a passing resemblance to a raisin.

A quick shower and a beer and then on a flight to the next outreach site.
But more of that in a few days.

On The Road Again

So another week another clinic, I'm getting some idea of what it is like for
a rock-star to be on tour, minus even the merest whiff of luxury. It seems
like every night I find myself in a different clinic. I exaggerate slightly
but not much. So this week I returned to the first outreach clinic I'd
visited. As any smarmy estate agent (and, though I've never met a non smarmy
estate agent, I presume them too!) will tell you it's all about location,
location and location.

The clinic sits on an artery road between two major towns and provides a
useful stopping point for people walking between the two. The fact that it
has, not only a water pump, but also a fabulous clinic just gives it greater
added value. This means there is an awful lot of traffic that just visits
the clinic for one day, making things like, (heaven forbid!) the review of a
patient the following week, impossible.

The heat on the road up to the clinic was searing. For various reasons we
left late and the sun was already racing upwards into the sky. It's a hard
sun here, the heat and power from it is unremitting. Shade can offer some
comfort but really, there is absolutely no escape. Whilst the walking is
easier in terms of zero water under foot, the heat makes it exhausting.
After a while it feels like your destination is no nearer and you've spent
the last hour on a treadmill. Hamsters stuck in wheels, I can completely
sympathise! Half my rucksacks weight is taken up with drinking water. It's
like being locked in a kiln.

The first night we were there we had a lot of rubbish to burn. I emptied the
various tins and papers into a big pit and dropped in a few matches. The
rubbish hole was just outside the fence (that was still standing following a
struggle to construct it the last time that can best be described as
colossal!), so I left it to burn.

About half an hour later there was an ear splitting bang from the area where
the fire was. Just as I had had time to check all four limbs were still
attached, another explosion, coming again from the direction of the rubbish
fire. This second explosion blew a large crater in the side of the hole and
scattered bits of the fire over a large area, part of a sardines tin landed
at my feet.

People from the clinic and nearby houses came to see what had happened. We
swiftly put the fire out, with copious amounts of water. It hissed and
steamed for hours. Everyone went back to bed none the wiser.

The following day I raked over the remains with a stick. In the bottom of
the hole were two empty bullet casings. Why someone had decided that a
rubbish fire hole was a sensible place to put live bullets baffles me,
thanks to me they weren't live any more!

Other than trying to avoid starting another war the main point of this visit
was to sort out the new 2007 contracts. This job was made much easier by the
fact that everyone got a whopping pay rise. Unfortunately the process
involved taking a few basic details from each member of staff….

Name- well most got that bit right, though sometimes the spelling was
different depending on what form was being written.

Village- again, not exactly straightforward, because here it is pretty
difficult to determine where one village begins and another one ends.

Date of Birth- No one had any idea what their date of birth was. The tax
form demands a date of birth.

So what do you do when you have a crucial form to fill in and a piece of
crucial data unavailable? You make it up. So come with me, dear reader, as I
show you how to both construct an entirely fictitious birthday and thereby
commit multiple fraud.

Marcus: So, do you know what was the date of your birth?

Staff Member: No, Not sure

Marcus: OK what year where you married?

Staff Member: 1986 or 1989, I can't remember (Which reminds me of that joke,
how do you remember your wedding anniversary? Forget it once! Clearly not
the case here)

Marcus: 1986 ok? Right let's say you were twenty then so that makes your
birth year 1966, sounds reasonable?

Staff Member: Yep

Marcus: Any idea what month you were born in?

Staff Member: Nope.

Marcus: No Worries. Pick a number between one and twelve

Staff Member: Erm… Seven?

Marcus: Right, July it is! OK nearly done, any idea what date you were born?

Staff member: No.

Marcus: Not a problem. How many cooking pots do you have at home?

Staff member: Four

Form: Date of Birth

Marcus: 4/7/1966

Voila! Born on the forth of July! This process has been repeated more than
thirty times so far and we aren't even half way. Painful.

Medically, we drained 65mls of fluid off an old blokes knee, (which was very
satisfying indeed.) and the workers in the clinic brought yet another child
with cerebral malaria back from the dead. Rather embarrassingly we turned up
just as the child was turning the corner and so got all the plaudits for it'
s remarkable improvement. Completely undeserved credit is no credit at all.

The walk back was uneventful apart from three very large trucks, the first
cars I've seen in six weeks, thundering down the track. All were laden with
soldiers. The lead truck stopped and the portly commander got out and
introduced himself. My heart was pumping like a train at this point. Trying
to remember what I'd been told to say to highflying generals/army commanders
in my briefing.

It's a bit like talking to the Queen in terms of etiquette. I settled with
just calling everybody 'Sir'. As he approached I looked at the back of
truck, which was stuffed to the gills with soldiers, all young, all armed to
the teeth.

I cursed the fact I hadn't any cigarettes to offer as a bargaining chip.
Being a non-smoker can seriously endanger your life, they should warn us.
Thankfully he was very jovial and offered us a lift. Whilst it would have
turned an hours walk into a few moments drive and was thus very tempting, it
's not quite the done thing and would have got me a flight home much sooner
than anticipated.

Pleasantries exchanged they drove off, the black faces and white teeth of
the soldiers in the back of the truck disappearing into a cloud of dust and
chocking acrid fumes from the badly tuned, gurgling engine.

Tomorrow we are off again, as the outreach travelling circus rolls onto its
next location. So more in a couple of weeks, when we are back in a land of
electricity and e-mails.

Forward and on

With a head still awash with numbers I got up early to try and finish the
statistical report. After a nights sleep it made even less sense and the
notes I had made seemed to be written in a language not of this earth. Never
mind, report dispatched, just have to wait for the feedback on it….gulp!

As is usual for the arrival of the plane, my preparedness was not exactly
that of military precision. Stuffing what clean clothes I had into a small
bag and grabbing a few biros and rushing towards the airstrip I arrived at
the gate and spun on my heal remembering I'd forgotten my stethoscope, I did
this little dance a few times as various other things came to mind that I'd
also left in my hut. The engines were running (A pilots way of telling you
to get yourself into the flippin plane... pronto!!!) by the time I clambered
aboard.

The flight to the outreach site was, if I'm honest, embarrassingly short. It
took just over five minutes to cover a distance that takes as many hours to
walk. The same pilot who flew us last time (and got lost, stop sniggering at
the back there!!) Flew us again and this time there was no mistake, the
airstrip was soon teaming with people who ran to observe this strange lump
of aluminium that had interrupted their morning. This was only the second
plane to land there in two years.

Anyway once landed things were pretty much as we had left them in December.
Everything was running well, various different problems had cropped up. A
few of these later. The BIG difference was the people who I'd got to come on
outreach with me. After a lot of pleading with the boss I'd scored a major
success. We had not only my new outreach buddy but also (da da
daaaaaaaaahhhh!) a Logistician. This I think was because, frankly, when it
comes to organising, things like logistics it's better to get
a ….erm…logistician.

Anyway with the various logistical bucks successfully passed we endeavoured
to try and sort out the medical side of the whole business. Moses (for it
was he again) was doing sterling work. Despite the fact that we hadn't
really worked with him since his arrival, he'd even managed to organise a
half decent off duty rota for the staff (BIG step forward)

The feeding program being offered to the populations' malnourished children
was disaster on every conceivable level. Sadly this wasn't his fault, and
therefore nothing we could easily correct. People seem unwilling or unable
to return for the repeat visits required in order to cure the malnutrition.
With a walk of six hours in temperatures that are in the low forties Celsius
it's not hard to understand why.

Medically the major problem was diarrhoea, no water pump still, it keeps
being promised by another agency…. never happens…out of my hands…tired of
being angry about it… Like so many before me I'm just a bit resigned about
the whole affair now. It's just so depressing,

The water level is lower and scarcer now so the quality has dipped still
further, the dirt is more concerntrated now. I'm not sure how this is
possible, but it is. A thick layer of brown slime sits at the bottom of any
large water container when you empty it. That's all I can say without
screaming!

One morning I was called to see a little girl with a piece of cow bone stuck
in her ear, another unbridled success for our friends in the traditional
healing fraternity. With a pair of tweezers and a lot of tugging I managed
to get it out, but not before causing significant pain and a bit of
bleeding. Hopefully incidents like that will get the message across.

It seems a bit weird that these trips become mundane but it's funny also
what you get used to. A new outreach partner has reminded me how odd this
all is compared to healthcare in the western world. But the numbers (for
this is what really matters I suppose) are better than ever and we seem to
be saving more lives than ever. I cannot describe what an immense
satisfaction that is.

We left a few days later with the majority of the staff for a large party in
the base site. There were speeches under the tree and the staff killed a cow
(and frankly I'm not sure the Iraqi government could have killed anything in
a much more gruesome way!!) and there was signing and dancing long into the
night, I have to admit I was so tired from the walk back that I sloped off
to bed at a conservative 11.45pm. A wonderful evening.

So the plan for this week is a wander off to another outreach site with
large numbers of soldiers and large problems. Will let you all know how that
goes!

Lies, dammed lies and statistics

It is possible to prove anything, they say, with statistics. Who 'they' are
has never been explained to me. Personally, the whole notion of statistics
falls into the 'spirit crushingly dull' tray of my brain. I even find myself
reading the subject bars of e-mails and the mere mention of the word
'statistics' or it's evil twin 'data collection' and it's straight in the
file marked, 'stuff to read when I'm old, unable to move, and barking mad'.

Yes, yes yes I know it's very important to know what is going on,
particularly in clinics where we are not present all of the time, this doesn
't stop it being about as interesting as creosote.

It's the one part of this job I loathe. Every month four members of staff,
one from each clinic, skip merrily through the sand and grit (that until
recently was a swamp!) with books full of numbers to one of the two base
sites. I then have to take the numbers and try and make sense of them. There
are a few problems with this.

Firstly, counting, as has be proved ad-nausem is not a strong point here. I
once made the mistake of trying to explain the concept of percentages.
Frankly I could have been reading a washing machine manual, backwards in
Serbo-Croatian for all the good it did.

Secondly, this is not the sort of environment that lends itself to intricate
and detailed compilation data collection. The fundamental problem is that
the clinics staff are not able to compile large amounts of information in a
monthly report and do the jobs they are supposed to be doing at the same
time. We just about manage the big three, malaria, pneumonia and diarrhoea,
but get into the finer detail and the whole thing comes down like a house of
numerical cards. The raw data provided is erratic. For some months I will
know how many pregnant women pitched up, for other months I won't. This
makes trying to identify patterns hopeless. Conversations with my bosses run
along the lines of;

Marcus: We had a large number of malaria cases in November.

Boss: Really? What about December?

Marcus: Erm…… (Starts to find floor very interesting, makes shape in sand
with shoe, avoids eye contact, or speech. Exits stage right.)

I have been sitting here all afternoon (yes I know, on a SUNDAY!) trying to
do the kind of mathematical gymnastics that would have had Archimedes
wondering if there wasn't some other topic to philosophise about. It's not
much improved after six hours of work. But at least the Excel columns are
now in different colours!!!! The guys who cracked the Enigma code are the
only beings on earth who can truly understand my pain!!!!!

Thankfully in just over twenty-four hours we are flying to an outreach site
to do some fun stuff. My brain may have stopped dribbling out of my ears by
then!

BREAKING NEWS. Just got an e-mail from my medical boss. There is a
nutritionist coming next month to assess our feeding program in the
outreach. Despite much effort our feeding program is an unmitigated disaster
on every conceivable level. I'm in so much trouble!!!!!!!

In the bleak mid winter.

It is winter here. I'm not exactly reaching for the bobble hat, gloves and
Bovril. Not much of a winter season by all accounts, it is still hitting the
mid thirties every lunchtime, but the early mornings and evenings are more
chilly, I'm sitting here in a long-sleeved top!! And it hasn't rained at all
since I arrived back. I know that's nothing to those of you looking out on a
snowy blizzard, but it's a big deal here in the desert.

No outreach this week, I've tried to operate them by remote control and
failed miserably. I've dispatched various letters with various questions and
received letters with various answers, which would be fine, except they aren
't answers to the questions to the ones I've asked!!!

First task of the week - brief my new outreach buddy, another UK nurse who
is as new to this game as I was not so long ago. She bounced in from the
other base, with a whole load of other new people. The number of expats has,
instantly, swelled hugely. The majority of them are from the UK. This has
had the unexpected bonus of meaning the office computer's spell check has
now been permanently switched to English (U.K.). Proof of a change in the
balance of power if ever there was one.

The reason for the coming of the proverbial cavalry has been the massive
increase in workload and having them here has (rather typically) coincided
with a significant downturn in the number of patients, leading to our new
arrivals all wondering what all the fuss was about. I was trying to explain
that before Christmas, vast areas of the clinic grounds were covered by
people sleeping on the floor, now they are as God intended. Empty. I think
they tried really hard to believe me. They will see when it all picks up
again!!! I'm staring to sound like one of those awful people who rattle on
about how it wasn't like this in their day!!!! Must make efforts to
stop......quickly!

Anyway my new outreach colleague seems very keen and eager so that is a big
improvement on the last two. We hope to head to our first clinic as early as
next week.

I've found myself doing briefings rather than listening to them, which is
VERY peculiar. It seems only yesterday I was asking the sort of questions I'
m now answering. I'm fielding enquiries about everything from security to
the rates of malaria in expectant mothers without batting an eyelid!

Every day here provides me with a new challenge, and I can't say that about
any job I've had before. This week included the usual mix of triumph and
tragedy. The child with convulsions (mentioned in the last entry) recovered,
against all the odds, and is now running around with his siblings. I'm still
none the wiser as to what it was, but something we did, clearly, worked.

The usual collision between the traditional and the western method of
healing has continued unabated. We lost a month old baby who, inexplicably,
had been fed cows milk since birth and had a very serious infection of the
gut. As things became terminal I gave some morphine and encouraged the
mother to breast-feed for the first time. The child fed beautifully. I left
the hut, wishing the mother had just done that in the first place and not
listened to the ramblings of some village wise woman, all very frustrating.

On an up (because I don't like to end on a down note) I did a refresher
lesson with the staff on pneumonia and not only had they remembered what I
taught them but they had also gone away and read MORE. Some of the detailed
questions at the end rather threw me!!!! Off now to brush up on a few things
about digestion before I get caught out again tomorrow.

To the place I was before.

After a fantastic, and by all accounts, much needed break I'm back. But no
outreach just yet as having returned from a holiday I'm now covering others
time off. This at least allows me a couple of weeks to get slowly readjusted
back to life here. How quickly and easy it is to forget what a harsh and
unforgiving environment this is.

The flight back in was, thankfully, much less eventful than the flight out.
>From the air it is possible to see the transformation in the landscape.
Sandy yellow is the new green. The change is little short of remarkable.
This area gets more rainfall than south east England, it just happens to get
it in just under three months (July, August, and September.) The rest of the
year is arid and dry. I was looking at photographs of what things looked
like in August and it is like a different county. Our airstrip, that only a
few months ago was ankle deep in water, is now a long, thin sand pit.

The wind whips around the mud huts and the buildings. It carries sand and
dust in every corner and crevice imaginable. Every surface is covered in a
fine film of it. The air itself is warm and a little like having a softly
blowing hair dryer six inches from you… permanently. And this, my friends is
only the beginning. Soon it's going to get REALLY hot.

By the afternoon of my arrival it was back to work with a bump. Various
patients, various problems, all in need of sorting out. Tonight I've just
returned from dealing with a child who was having a nasty convulsion. The
fitting we have managed to stop, but as might be expected he remains deeply
unconscious. He has no fever and the malaria test is negative so I'm not
really sure why he is convulsing, there is a list as long of my arm of
possible causes. We have given everything and covered all the bases
possible, I've just had a bit of a chat with the mum and dad and they seem
quite clued up. The situation is, needless to say, dire. we will see how the
night goes, but it is not up to me anymore.

So a few weeks here and then, hopefully some outreach, with a new outreach
buddy who is currently in the other base, doing a similar job to me. There
is also a staff party to organise, so I won't be sitting around.

I hope you are all struggling back to work ok, for those who have e-mailed;
apologies for my hopelessness I will sit down and reply soon.

Crash, Bang, Wallop!

Before I start I will say that the fact that I'm able to write this means I haven't lost the use of my arms, or hit my head so hard that all my food from now on has to come via a blender. For a brief moment yesterday this outcome was not a certainty.



The day had started regularly enough; I had packed my stuff into my rucksack and was trying to sort out various things in the clinic before flying out for my holiday. This involved sweeping my arms across the desk and depositing all the paperwork I still had to do into a large metal trunk. It can wait until the New Year…probably.



The roar of engines overhead indicated an immediate arrival and departure. The aeroplane thundered across the barren ground billowing sandy dust in its wake. Soon we were bumping along the runway before a roaring departure from terra firma and into the brilliant sun and bright blue sky. After a stop at another project to pick up some passengers we were skimming across the clouds to the missions base.Flying here is so standard it has become a little like a bus or a tube, I have become a bit blasé about the whole enterprise.



The plane slowed as we approached the tarmac of the airfield, the only place we land with tarmac. The flaps wirred into life, the ground rushed to meet us. I really wasn't paying attention. My book ('Rubbish' by Richard Girling) was very diverting and we would soon be on the ground and taxiing, and I would soon be off on holiday. So to summarise I really wasn't prepared for what happened next.



As the plane touched the ground there was a very loud bang. When I say loud, I think some of you in the UK might have heard it and wondered what it was. This was followed by an equally worrying 'wararah wararah wararah' noise. The plane shuddered violently and lurched across the tarmac. Up front, the pilot flicked a few switches and was engaged in a struggle with a plane intent on leaving the tarmac and becoming intimately acquainted with the airfields perimeter fence. As we careered onwards the aircraft adopted a sort of strange diagonal position, a bit like a bad skier trying to parallel turn.



Eventually, after a further loud bang, and more violent shuddering we began to slow down. By this point my skin that had turned the colour of Tip-ex and my eyes were the size of large frying pans. If I had had rosary beads (and, perhaps more importantly, been Catholic!) they would have been a pile of sawdust.



When a tire blows on a big plane like a jumbo jet you don't notice, there are loads of other wheels able to take the strain. Sadly I don't work in place that would accommodate your average 747. In small planes it is a big deal! We had lost one of the three wheels. As we got out of the plane, the damage was clear, a tyre, flat and shredded a landing gear that was sitting at an angle that made the plane look like it had been designed by a drunk four year old. There was also a very nasty new groove in the tarmac of the airfield. Nobody seemed to care about this.



My huge thanks, obviously, to the pilot whose skill prevented a much worse situation, but defiantly something I don't need to repeat.



Anyway, safe and sound, I'm off for a break until the 5th of January. I'm also having a holiday from blog. I'm sure you will all be too busy to read it anyway. Thanks for coming with me in 2006 and hopefully pick up where we left off in early 2007. Happy Christmas and New Year one and all.

---

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Triumph and Disaster

So a week at base camp, and the place that I would call ‘home’ out here.
With no outreach buddy anywhere to be seen I have been kept busy in the
inpatient department. A variety of staff holidays and, what in the business
is called a ‘high patient flow’ (i.e. clinic busting at the seams!) means I
haven’t exactly been idle. The basic figures are as follows. Discharge - 43,
died - 7, admitted - 58. Behind every number is a story, some tragic, some
remarkably uplifting; one of each to follow;

Yesterday we tried to resuscitate a twenty-eight year old man who had
advanced tuberculosis. He had been sick for some time. Sadly there was
‘something else going on’ which is what we term any condition that we cannot
diagnose due to a lack of facilities. Basically we went for hit and hope
treatment. Take an educated guess as to what it is and cross you fingers.
Inevitably we sometimes we get the calculation wrong.

The man was showing signs of acute liver failure and had begun bleeding
heavily internally. I managed to site an IV line and the blood that flowed
was very dark and thin, indicating he was not getting enough oxygen and the
iron level in his blood was dangerously low. A lab test confirmed as much
(Hb of 1.5, yes, I know, 1.5 for the medically minded).

Blood donors only come forward at the last moment and the only
people who donate are members of the immediate family. Sadly none of this
family matched the patients’ blood group. His condition nose-dived in the
mid morning. We struggled to rescue the situation, for every problem we
addressed another two would crop up. In the end the man became very
distressed and agitated, sensing, I think, that time was short. We gave him
a generous dose of diazepam and he gurgled, foamed and convulsed until he
was finally gone. Our national staff were magnificent, considering that the
patient was a personal friend of some of them. I can’t say it was anything
other than horrendous.

Earlier in the week we had seen a child with cerebral malaria.
He was very lethargic and didn’t flinch when we put IV lines into him, which
is never a very good sign. Round the clock observation and high doses of
antimalarials seemed to be getting us nowhere. I decided to have what is
referred to as ‘the chat’ with mum and dad. The chat can basically be
paraphrased, as ‘unless there is some sort of miracle your relative is not
going to survive this’. It is useful in preparing the family for, what is
often, the inevitable demise of a loved one, but it is not exactly easy.

Slowly, very slowly, the little boy began to show signs of
improvement. He began by moving an arm and sighing (as if he found the whole
thing a bit boring). By the next day he had opened his eyes and rolled over
onto his side. Today he was playing with his siblings, and grinning from ear
to ear, my whole year is worth it just for that.

Whilst the individual success stories are, personally, the most
rewarding many more lives are saved by prevention. This week there has been
a much-needed push to improve the care we give to pregnant women. The
newborn fatality rate here is astronomically high. Pregnancy and childbirth
are a leading cause of death in women. It is not difficult to see why. Most
babies are born at home with only a village wise woman (without any training
but lots of experience) in attendance. The babies are delivered onto a muddy
floor, they often aren’t kept warm enough, they may be two days walk from a
health centre should problems develop. The vast majority of mothers have
received no antenatal care whatsoever, and are very anaemic. A consequence
of this is that they bleed heavily and often die.

This situation is compounded by some damaging health beliefs that are
commonly held here. The babies’ umbilical corn is cut with a rusty blade and
the stump is often smeared in cow dung, leading to tetanus and infection.
For the first three days the baby is fed on goats milk, as it is believed
that colostrums is bad for the child. Establishing breast-feeding after this
is very difficult.

We only see deliveries in the clinic when all other avenues have been
attempted. The traditional healer, the old ladies and a multitude of wise
women have had a go at getting baby out and failed.

By this time the mother is often tired, the baby more often than not is dead
and there is precious little we can do about it. Destructive delivery is
often the only feasible option, and I can’t begin to describe what an
unpleasant business that is.

As an attempt to stem this lethal tide we have been constructing and
improving home delivery kits. These are kits given to pregnant mothers for
use in delivering their child. They consist of string to tie off the
umbilical cord, a razor for cutting the umbilical cord, soap for mum and
baby, cloth and blanket to wrap the baby in, gloves for whoever is helping
in the procedure and a large plastic sheet in preference to a muddy floor.
Simple but, all the research indicates, very effective

Their construction rivals Wembley stadium in terms of length and problems! A
committee of a few of us (being the only children’s nurse got me mired in
this particular adventure!) have met to discuss various aspects of the kit.
What do we include, what not to include, how to train mothers and so on. The
‘do we need a plastic bag for the placenta’ argument dragged on for weeks.
Finally resolved we began to give out the kits this week.

Obviously first on our hit list was the clinics staff. I held a large
teaching session for all the staff that wanted to come. I proceeded to open
up a kit, mime having a shave with the razor, I blew up one of gloves like a
balloon bouncing it up and down and took a bite out of the soap (which was
stupid).

My point being that if we don’t teach mothers how to use the kit we may as
well not give them out. It at least got a laugh and hopefully made the
point. I finished by telling them that as there were twenty of them there if
they each told five pregnant women to come and collect a kit that would help
to save the lives of one hundred babies and one hundred women. Back to
numbers again

So health interventions in there mega and nano versions this week, what will
happen next? Your guess is as good as mine.

All change please, all change

To grossly misquote Wilde 'to lose one outreach partner could be seen as a
misfortune, to lose another smacks of carelessness'. Of carelessness I am
clearly guilty. The revolving door that is the outreach nursing team has
sprung suddenly into life again! Francis has decided outreach really isn't
where he wants to be. This coupled with a very attractive masters degree
offer has led to him beat a hasty retreat. From resignation to departing
took less then ten hours.

It's obviously very disappointing but this isn't the sort of work you can do
if you aren't fully committed. In honesty he wasn't happy about the set up
here from the moment he stepped off the plane. And towards the end of our
time together it began to show. It has been a bit difficult, but everyone
has been really supportive and reassured me that it isn't my fault I was
beginning to wonder!

I've been keeping myself busy by helping out in the base clinic which is
starting to resemble an Accident and Emergency waiting room with patients
almost sitting on each others laps! The edited highlights of my week to
follow in the next few days.

A, now much needed, holiday is fast approaching. I actually escape next
Friday for a few weeks, though plans are a little fluid at present.

Are You Chicken?

I want to honour a food that I’ve grown to loath. It’s the perfect fodder
for aid workers toiling in war torn areas, such as this one. Arriving in its
own bulletproof vest, know commonly as a tin. It has tried to make its mark
on the culinary landscape of many a project.

In fact there is only one thing holding this great food back from global
domination, at least when it comes to feeding those who have little option.
It is practically inedible. I refer to chicken luncheon meat.

Even the name is misleading. Luncheon is the term that, the queen and
well-to-do pearl encrusted Daily Mail readers use to describe the meal in
the middle of the day.

This food would not exactly be on the menu at Buckingham palace. It would
struggle to get a look in at the workhouse in Oliver Twist. Certainly if it
was, Dickens great masterpiece would have taken a very different direction.
Young Oliver, carted off, lethargic, green and vomiting, to hospital after
managing to finish a portion of the offending item. ‘Please sir, can I have
a stomach pump?’

Created by Regal of Mauritius it is 260g of pure bile. It arrives in a
cylindrical tin an inch tall and two inches in diameter. If I had my way it
would go straight from factory to landfill without ever being offered for
human consumption.

The picture on the front of the tin displays what appears to be a large,
pinky-orange, sliced sausage surrounded by, rather tired, looking lettuce
and tomatoes. It even has the audacity to site this as a ‘serving suggestion
’. What exactly are the manufactures suggesting? Remove from tin, cut into
bits and put with fresh food in an effort to make it look appealing, not
exactly Jamie-flippin’-Oliver is it?

The ingredients listed, thankfully, include chicken meat, which I must say
came as a bit of a shock. Red rice and phosphate E451 are present which I
would feel happier about, if I knew what they were. Finally, in this
concoction, is the sinister sounding MSG E21, which sounds like the sort of
thing used to kill off dissident Russians.

I made the mistake of bringing a tin to outreach with me. By the end of the
week we were running a little short of grub and I decided to try an
incorporate it into a lunch (eon). I felt this was particularly important,
as I had just had a bit of a go at the clinics pharmacist for letting a few
boxes of drugs expire and the luncheon meat was a month of expiry.

I broke the tin open with a rusty opener and dug in with a spoon in the way
a normal person might eat yoghurt. I could just about see the rings of the
base of the tin when I began to feel very sick. Even as a student I was
never driven to try cat food, however chicken luncheon meat is as near as I
ever want to get. I fed the rest of the tin to an emaciated passing dog, who
didn’t finish it.

The fact that a poor animal has had to sacrifice its life in the creation of
this product makes even this carnivorous bloke come over all Linda
McCartney. I’m sitting with a tin in front of me as I type this; (funnily
enough we have stacks of the stuff in the store!) and I’ve just noticed one
slightly redeeming feature. The product claims to be Halaal, meaning that a
huge portion of the world’s population is able to see exactly what I’m
talking about for themselves, multi faith excrement indeed.

So here's to you Regal, creators of a food that even people who are really
hungry would rather chew on broken glass than eat. Chicken luncheon meat I
salute you!

Ten Things I’ve learnt Since Being Here.

I’m nearly at the halfway mark and I’m in retrospective mood. So I thought I
’d write down a few truths that have become apparent since my arrival. In no
particular order here we go……..

1) The notion of ‘sterile’ is a relative concept.

2) Any medical device, including IV lines, Naso-gastric tubes,
catheters etc can be made to attach any other medical device if you push the
two ends together with enough vigour!

3) Any food in a tin (cheese, mackerel, peaches etc) can become
strangely addictive.

4) Chicken farming is much more complicated than it would first appear.

5) People will work through the most extraordinarily difficult
circumstances with, almost nothing, to keep a clinic open. And save hundreds
of lives in the process.

6) How the western/‘developed’ world deals with the African ‘problem’
leaves an awful lot to be desired.

7) Having said that foreign aid CAN make a difference if (and it’s an
oft forgotten ‘if’) it is directed in the right way. When this does not
happen it often does more harm than positive good.

8) The IPOD solar charger is beyond criticism.

9) Sometimes even the simplest improvement in practice can yield
fantastically impressive results.

10) The world isn’t fair. I think I knew this already, but the last few
months have confirmed it.

Cometh The Hour, Cometh The Man.

Moses (of bible fame) was a very interesting bloke. His ability to cast
asunder large bodies of water would be particularly useful to many an
outreach expedition. Whilst his namesake, as far as I’m aware, is unable to
do this he did manage to save both the clinic and my frayed nerves!

One of the staff, David, had mentioned that there was a health worker who
lived not far from the clinic. He hadn’t worked for a few years and had been
doing other things (attending theological college for one) but he was
currently not working. David hadn’t finished his sentence by the time I had
written the letter to this man inviting him for an informal chat.

Moses, the health worker (Not the bible bloke, otherwise I really would have
something to write about!) strode through the early morning mist. He greeted
me with a bone-crushing handshake. He was a tall man, with a short beard and
voice ten octaves below baritone. It wasn’t so much as voice as a low
rumble. The sort of tone that could really put fire and brimstone into any
sermon.

As we spoke the sun broke through the clouds and cast the clinic in a
brilliant white light. A heavenly sign? I hoped so. A few moments later all
was well, the clinic had a new supervisor and I had stopped at least some of
my hair turning charcoal grey. We had been eight hours from closure. I never
want to be that close again.

Moses started the next day and whilst there were a few bits that had lodged
somewhere near the back of his brain they seemed to jump easily enough into
his working memory. I am sure he will be fine.

Very pleased with ourselves we half walked half skipped back to base, where
I am now, chilling. The next few weeks’ movements are a little up in the
air, but a holiday is defiantly on the agenda.

Spot The Healthworker

Regular readers of my musings on this blog will be aware that about a month
ago I had an outreach visit that involved a human resources nightmare. I had
hoped that the whole thing had rather blown over and I wouldn’t need to
discuss it again. It didn’t so much blow over and blow up!

Our outreach clinics are overseen by a supervisor who has been given nine
months training in all things medical and sent out to run the clinic and
treat whatever falls though the door. The rest of the staff effectively
operate in support of him, doing malaria tests, giving out medicines,
fetching water etc etc. Anyway, to say this member is crucial to the clinics
survival is to say money is reasonably important to Donald Trump. Without
this health worker the clinic does not open. Full stop.

A short version (the long version might put me in therapy) is that the
supervisor of this particular clinic managed the following during the last
visit;

He picked an argument with us for absolutely no reason at all. Then, when
informed in the most reasonable voice I could muster, that this was
unacceptable and that he should consider his behaviour in future he walked
out in an overly dramatic, eye-rolling strop. Walked out, I might add
straight into the arms of another NGO and a near tripling of his salary.
Just be glad there weren’t any large or sharp objects in the immediate
vicinity. I was a tad peeved.

So this left two outreach nurses playing an increasingly frantic game of
spot the health worker. Initially we solved the problem by dragging a
substitute on from another clinic. The problems really started when he also
(for valid enough reasons) had to leave very quickly too.

We found ourselves hot footing it back from one outreach site and straight
onto a plane to rescue another. Things didn’t go quite according to plan
from the outset when the pilot keyed the wrong coordinates into his GPS and
flew us in totally the wrong direction. Thankfully Francis was much more
awake than I was and pointed this out. 12,000 feet is not the sort of
environment that facilitates easily stopping to ask for directions. After
scrambling around with maps we resorted to flying to somewhere near it
(which we had the coordinates for) and circling until we spotted the
village. This accomplished the plane was onto the dusty savannah in a matter
of minutes.

The first thing to do was to hold a staff meeting. We informed all the staff
that we would be seeing the patients ourselves for the week and sorting out
the health worker vacancy at the same time. In truth it had all gone (to use
the south London vernacular) pear shaped. We hadn’t a clue where we were
going to find someone. The situation was looking bleak. Clinic closure and
redundancy loomed large. I don’t think either of us slept very well.

Some very sick patients compounded this state of affairs. The worst was a
two-week-old baby who attended the clinic and had been seen by both of us.
He looked very well, he was feeding well and mother had few concerns. She
had actually attended with her other child, for her to be seen. The next day
the mother came back, this time with just the baby in a basket. As I took
the covering off the basket it was obvious that things were very serious. A
confirmatory listen with the stethoscope was the evidence. The babies’ heart
rate was extremely slow and the breathing was shallow and gasping. Fifteen
minutes of frantic efforts were not enough and, sadly, the baby passed away
as I held him.

There was no temperature and the child seemed well nourished and cared for,
I have absolutely no idea why the baby died. Infant mortality statistics
look a whole load different when you see them in flesh and blood. The
parents took the child home in the same basket that they brought him in.
Another Tuesday morning in Africa.

The people here accept child death as a norm, of course losing a child is
unimaginably painful, and I know they feel grief just as acutely as anyone,
but
children dying here is also greeted with a sad resignation, rather than
surprise.

A deeply depressing few days indeed, to depress myself further I looked
through the clinic records and found that many of the patients lived hours
walk away from the clinic and that its closure would cut a swathe of them
off from any healthcare at all. Furthermore the clinic was seeing patients
who were critically ill. I estimated that closure could cost 150 lives a
month.

The land where 'yes' is 'no' and 'no' is ......um...

“Yes” he said, “no, lets just get this clear, you are saying the pump is
fixed and working well,” I said “yes, yes” he said, “new pump, put in by
UNICEF. very good”. These words were still ringing in my ears as Francis and
I stood by what was a very new but (as might have been guessed) very broken
water pump.

The meeting with the tribal chief had been a useful one in that none of what
he had told us about the outreach clinic accurate. In fact in almost every
case the reverse was true. The people weren’t getting sick from drinking
dirty water (they were), the clinic fence had been repaired (it hadn’t) and
there were no military forces in the area (again, a bare faced lie!!).

The walk to the outreach site was uneventful, gone is the mud, replaced by
rutted tracks and smooth sandy paths. The sun is burning the vegetation away
from around us, with all the delicacy of a blowtorch. Not much has remained
unaffected and everywhere is yellow and dying.

As we walked along we passed though a village where the population seemed
very pleased to see us. Laughing could be heard in various houses and from
behind trees and bushes. In the distance men danced around and fell over. It
became obvious; as we got closer that everyone in the entire village, over
the age of four, was drunk.

The harvest season has just finished and the people here are able to make a
sort of wine homebrew. Clearly this village had enjoyed a bumper crop. Even
more impressive that they had managed to reach this level of alcoholic
stupor by nine thirty in the morning. It was like Liverpool on a Saturday
night. In some ways it might have been fun to stay and see what happened
when the party really got going! Another time.

The outreach clinic was running very well despite numerous problems. The
most comical was a difficulty experienced with weighing the children. In
order to do this we use a pair of dungaree shorts hung from what looks like
a butchers scales, suspended from the branch of a tree. Unfortunately the
bloke
doing this had a nasty habit of hanging the scales upside down. This led to
some babies weighing in at a stonking 25 kilos. A marker pen and a ‘this way
up ‘arrow soon solved the problem.

Statistics will, if you believe them, tell you anything and in this case I
can tell you exactly what date the pump broke (Wednesday November 3rd just
in case you’re interested). Why can I tell you this? Because three days
later we had an 67% upsurge in cases of gastroenteritis, we saw 33% more
wounds that week, caused by having to walk through a swamp to get to the
deeper drinking water, and a whooping 56% increase in eye infections, from
washing with, yes, you guessed it…filthy water.

The patients were drinking their medicine in the clinic with water that
looked like the sort of stuff found at the bottom of the sink after washing
up (for those of you who’ve lived with me, yes I am aware of what washing up
water looks like!). Putrid is the only way I can describe it. What is
particularly ironic is that we are giving them medicine to treat, amongst
other things, diarrhoea. And then we get them to knock it back with water
that you wouldn’t wash your car with in the west. I’m beginning to bore
myself about the water so I’ll stop now. Point, exhaustively, made.

The saddest case we saw involved a little girl who had been shot in the hand
during fighting four days earlier. The bullet had taken away a chunk of skin
at the base of her thumb and blown one of her fingers clean off. She wore an
expression of confused bewilderment, too young to understand the nature of
what had happened to her. As I lay awake that night listening to the
sinister rattle of machine gunfire I wondered what would turn up at the
clinic the next morning. Nothing did arrive, the optimist in me would like
to think that’s because no one got hurt. The realist thinks it’s probably
because they were beyond our help.

The staff themselves were all doing various jobs with an impressive degree
of efficiency, which considering we hadn’t visited in months, leads me to
think that actually it would be better if we just stayed at home and stopped
interfering. We were even able to promote a few which was fantastic for
them, and, I hope the clinic.

The high moral was shattered with dreadful Mozart cover version - the ring
tone on the satellite phone, which I can’t manage to change.“Hi Marcus, it’s
me (the boss). Listen there’s a bit of a problem, we’ve had to close one of
the clinics, the supervisor has resigned” “Resigned? You’re kidding.” “No”
she said. And, she meant it.

H2 oh!

I am going to have a Geldorf moment, it is my first for a few months. I
think it's really in important, and I don't mean 'I think it's really
important' in a David Cameron 'I'll say anything is really important, just
as long as you vote for me' kind of a way. By all means ignore my rant and
come back in a few weeks when I've done some more outreach.

The chances are, as you read this, you are sitting fairly near a tap. And if
you were to get up and get a glass of water it would not cross your mind
that the water you are drinking could kill you.

Envisage for a moment that the water company decided one day to stop
supplying water to your house. (For those of you who pay vast sums of money
to Thames water every year for truly appalling service this won't require a
giant leap of imagination!)

Now picture a scene where, not only do you not get water to your home, but
not to the street where you live or even the distance between you and your
place of work.

And now imagine your nearest source of clean water is three hours walk away.
And you can't drive because there isn't a road. And even if there was, you
haven't got a car anyway. Part of the route involves crossing a swamp.

If you think this situation is bad, we haven't really started yet.

So the water pump is three hours away, and obviously it's not just you in
this predicament. So, you spend vast parts of your day either walking to the
pump or queuing to use it. You also need to carry the water you've collected
back, in a cracked, plastic container that splashes your precious clean
water across the countryside. Full, it could weigh up to twenty kilograms.
Oh, and did I mention that it's forty degrees in the midday sun?

However there is an alternative. Just near your house is a moderately sized
swamp. Obviously, the water isn't clean (in fact it's the swamp you use as a
toilet) but it's much easier to get to and you can get much water everyday.
So you decide to use this water instead. Dirty water is obviously not ideal,
and lo and behold your children become sick, and so do you. So your walk to
fetch water is punctuated by regular bouts of infective diarrhoea and
vomiting. Furthermore because you didn't get any type of formal education
you are completely unaware that it is the dirty water that is causing all
this.

In order to solve this problem you hear that the advice from the health
service (which consists of a single clinic two hours walk away) is to err.
drink more water.

If you live on planet earth you have a one in three chance of drinking water
from an unsafe source. That a situation like this should be the case in the
early twenty-first centaury should shame us all.

I'm away again tomorrow so no blog for a few weeks. Sorry that was all a bit
heavy. Go and have a glass of water.

A Bugs Life - The Story of Atomic Geckos.

I was actually going to write about something else this evening, but my mum
e-mailed this afternoon and said she wanted to know about the wildlife. I
realised I hadn’t scribbled much on the various creatures that inhabit this
area, a glaring omission indeed. So here in short is the low down on the
various aspects of wildlife here. (Chickens and cows excluded)

I think the real reason I haven’t mentioned anything about the animals here
is that it’s a bit like asking me about modern art. I haven’t got a clue
what I’m supposed to looking for or at! There are birds here of various
shapes and sizes but I haven’t the slightest inkling what they are called.
During the last walk we did I commented on the goats in the clearing next to
us. I was informed they were, actually, sheep. In short you’ve asked the
wrong bloke. But anyway, here goes!

As well can be imagined this is not the sort of place that people come on
safari. I don’t spend large parts of my outreach walks standing on the side
of the road watching open topped Landrover Discoveries with kaki clad
tourists, speed past.

The water situation prohibits and of the big five - Elephants, giraffes (I
can’t remember the other three…. is one of them skunks?) from being here.
The land simply isn’t stable enough to support large numbers of lumbering
animals (Apart from me!). It fails to support human life adequately.

We do a good line in snakes, of the toxic and non-toxic variety and the
clinics sees a fair few bites from both types. Before this the only bite
from an animal on a human I’d ever seen had been a woman who had been bitten
by a squirrel. Curiously we also see a high number of people who have had
snakes spit in their eyes, which I’m told feels like someone has just thrown
boiling water in your face.

However where this area really excels is in the realm of insects. At primary
school this group were referred to as mini beasts. Less of the mini here
sadly. You only need to leave a torch on for a few moments to see swarms of
various different creepy-crawlies congregated round it. As I’m sitting here,
a lamp on the table near me has hundreds of creatures buzzing around it as
if at a rave.

By far the most feared of these are, of course mosquito. Responsible for
more deaths than all wars in history combined the mosquito wreaks havoc
daily. The particular variety here seems to have the ability to treat
repellent as a mild inconvenience and punch through two layers of clothing.
In fact nothing, proves any deterrent at all and you get the feeling they
could probably bite you if you were dressed in a suit of Kevlar.

To say this area has a fly problem is to say George Bush is a slightly
incompetent president. I’ve just about got used to them crawling everywhere
except my face. Maybe in a few months I won’t care about that either. The
local people here seem able to ignore them completely. They adorn the
childrens faces like bizarre jewellery. Occasionally on a walk I’ll swallow
one by accident, which I supposed provides me with some much-needed
sustenance, but isn’t to be recommended if you can avoid it.

The other much feared bug here is the scorpion. Able to punch so far above
their weight it’s laughable, they are a real problem. No bites for me yet
but I’m told when it happens you know about it. Thankfully actual fatalities
are rare, though it does paralyse the limb affected for a while, which can’t
be a pleasant way to spend an afternoon.

The way Iâve found to deal with them is to encourage them to the floor and
place my foot on top of them and then scrape backwards in the manner of an
irritated donkey, they tend not to recover from this method.

Speaking of our sad grey friends, donkeys are also abound in number, though
it’s difficult to work out exactly what they do all day apart from wander
around the place looking melancholy.

And finally the humble gecko, possibly my favourite animal of all time, for
two reasons.

Firstly they eat flies and so in many ways we don’t have a fly problem but a
gecko shortage. Secondly their use of Van-Der Waals theory of atomic
attraction to climb walls and ceilings. Yes, I’d never really thought about
it either.

For those of you unfamiliar (as I was until it was explained to me last
night) it goes as follows. All atoms exert a small amount of attraction on
every other atom. Geckos have microscopically fine hairs on their feet and
an excellent weight for surface ratio meaning they literally stick
themselves to the wall at an atomic level. So that’s one for the pub
tonight.

On that note, the various arachnids that were finding the lamp attractive
are now beginning to congeal around the light from this laptop so it’s time
to leave you to type gecko into Google and see if I’m right.