Long live the NHS

Every day I learn something about the way culture, superstition, religion or tradition affect the care that patients expect and receive in hospital. For example with pregnancy. In Tanzanian culture pregnancy is hidden because being pregnant increases the mother's vulnerability to social or physical harm. If she miscarries or has a premature baby it might be thought she had attempted an abortion. Medical notes never state a woman is pregnant. Instead they will say she has not had a period for say, 9 months. There is no noise from the delivery ward where women give birth alone, without a sound or pain relief. When a baby dies during delivery mothers are not meant to cry or hold the child and often they do not get a funeral. Instead the mother has to bury them outside the village. It is very hard to work to improve the care that babies and children receive in a culture where newborns do not get a name for the first month of life because they are not yet a person.

At the other end, when a patient dies there are no ambulances to carry the body home. Relatives pay for a bejaj (tuk-tuk) or a piki-piki (motorbike) to take the body back to their village. In the case of a piki-piki, the body is sat upright between 2 other passengers and driven home for burial. In the meantime, a simple mortuary is on hand - a raised concrete slab in a building with slit windows that has no refrigeration. Most family members prefer to be told that there is little hope for their relative so that they can get them home while they are still alive and easier to transport. Death is accepted in as stoic a fashion as birth. But very occasionally there is a terrible wailing from devastated relatives who have been told their son/daughter/father has unexpectedly died. At these times, we staff stand around awkwardly, waiting for the sudden outpouring of grief to be ushered away somewhere out of sight and earshot. Overnight deaths are presented in our morning meetings by announcing, "in ward 1A at 3am, the patient stopped breathing". This is enough to declare death because no resuscitation is ever attempted. What for, when a patient can't be intubated or monitored with any equipment more advanced than a blood pressure cuff?

The ICU

Around the hospital, patients sit on the floors of the open air corridors waiting for blood tests, waiting for outpatient appointments, waiting for prescriptions, waiting for their turn in theatre. Beds are lined up along the wall outside of theatre for those that cannot walk there by themselves, wheeled by their own relatives. Patients with open fractures or septic wounds attract the flies in the heat. Inpatients who require blood tests are sent to the laboratory to wait, maybe all day if the lab is really busy. Mothers and babies sit on the floor for hours, then return to the ward with their results and wait again until the next day when the doctors come around.

Sometimes on the children's ward there are several patients to a bed, including the mama's and bibi's (grandmothers) of the patients, who come to take care of them and make them food. No meals are provided by the hospital.  If someone doesn't have a family member to cook, they don't eat. Relatives stay in a concrete accommodation block next to the hospital; a large room where everyone sleeps together under a bright fluorescent strip light. The chimneys are blocked and in the evening smoke from the cookers funnels out of the glass-less windows. At night the hospital doors are locked but you often see relatives passing packages through the holes in the walls to their family inside.

Children's ward and the table where all procedures are carried out

Today, there was a 1 year old child on the ward who was struggling to breathe and desperately needed oxygen. They looked like they were dying to me. Mama wouldn't agree to treatment until her husband could be consulted. When he eventually arrived and approved, the nurses were reluctant to administer the oxygen because if the child died they would be blamed; the superstition being that if you give oxygen to a patient it will kill them.

Surgical wards

Medication rounds consist of the medical attendants, or a nurse if the ward has one, standing at a table with a pestle and mortar, shouting each patients' name until they come and collect their or their child's drugs. Even if they had a caesarean section that day, the women come padding along from their beds, babies tied to their backs or attached to their breast. For the infants, all tablets are crushed and emptied into a small cup - few liquid medicines here - no doubt they get some of the drugs from the patient before them and who knows what actual dose they receive.

Staff are always attending educational meetings and training sessions but whilst the NGO's that organise this teaching are well-meaning, they have little idea how things work on the ground. People go to these courses, eat the chicken offered at lunch, drink the sodas, catch up with friends, then go back to their work and never use or share any of the information they learn. And in their pocket they carry the 10,000 shillings (or more) that they get; per diems for attending the course in the first place.

Once you accept these challenges and the many others, it's possible to start making small inroads and changing things for the better. But it's polepole (slowly slowly) as they say in Africa and it's a long, sometimes frustrating journey to get the respect and trust needed before you can mend even one small thing.

No wonder our placements are 2 years long. Nothing can be done in a hurry.

But you may call me Clara...

This is my new name, here in Tanzania. Claire was proving too difficult to pronounce so we have settled on a more exotic adaptation. I enjoy it when someone exasperates "Oh, Claaaara!" after I've said something inappropriate, yet again.

My integration into village life is moving along. We had chapattis home-delivered in the mornings which was lovely. Then the price of a chapatti rose 50% allegedly due to an increase in the cost of flour. After researching that no other chapatti vendors had raised their prices we decided to make a stand against wazungu rates and put an end to our regular delivery, a shame for all. But on the upside I am now getting maziwa freshi (fresh milk). Half the village was on the look-out for a cow for me. The first few leads I had came to a dead end when the cows' milk supply dried up. Then someone knew someone who knew a man who knew a cow in the next village. Three days a week a boy arrives at 6.30am in tatty clothes, home-made rubber sandals, and riding a bicycle too big for him. He fills a soda bottle with milk from a bucket strapped to the back for 20p. It smells of Fanta Pineapple and is diluted down with water but it's fresh. I used the whole bottle to make a hot chocolate yesterday. Even though it's 35 degrees, sometimes you miss treats from home. Eggs we buy by the tray from Dr Mmambale in Internal Medicine, roasted coroshos from Mama Joseph who lives in the village and sells cashews to help her look after the grandchild she adopted when the parents left, dried fish comes from the fish-man whenever he passes through the hospital, and sour-dough bread now and then from the Convent. Enough to feed the 5000.

Valentino's container shop in the village - one of only two places to buy toilet roll

Occasionally, staff at the hospital ask whether I want a cleaner or cook. Some volunteers have employed people to help at home and whilst it's tempting and will provide somebody an extra income, I am keen to do as much as I can by myself and not encourage the notion of rich mazungu. Though, I am seriously considering finding someone to do my washing. It's a full day job - soaking, scrubbing, rinsing, wringing, drying. Can't wait for when the launderette opens in the village. I used to string the washing line up between the banana trees in the garden but I've started to dry clothes the Tanzanian way which is to lay them on the grass to dry in the sun . It's a tough life.

James has given his first cake-baking masterclass. Mama Pepe who runs the mkahawa (cafe) where we have our lunch each day and Mtalika one of the laboratory staff came on Sunday to learn how to make mango, banana and coffee cakes. It was exactly like an episode from Masterchef minus the chefs whites and with more ants. A successful event not just for the quality of cake but also for the cross-cutting religious and gender awareness issues it involved; Mtalika being a Muslim male and Mama Pepe a devout Catholic. My role was photographer, pot-washer and ant-whisperer. Mama Pepe brought James and I half a chicken as a thank-you, which made a tasty (if a little tough) chicken curry.

Hopefully it won't be long before Mama Pepe invites me for another cooking lesson at her home. The first time she taught me how to cook fish with a tomato and coconut sauce using a traditional Tanzanian jiko - a charcoal oven. If the temperature gets too high, you just remove some of the coals. People cook outside; it's too hot to cook indoors and besides, most homes don't have kitchens. Meals are a social occasion - everyone sits on a large mat and shares food from a communal plate, using hands to form balls of rice or ugali (stiff porridge) to dip in whatever sauce there is.

Mama Pepe's cafe - our regular lunch spot

Mama Pepe's "kitchen"

The time came to finally eat the second Christmas Pudding and Ambrosia custard that came with me from home. I really wanted to give the leftovers to the askari who was outside in the dark. I was torn - do I offer the finest Waitrose pudding soaked in VSOP brandy to the hungry Muslim guard? In the end I woke him up from his (high-alert) slumber underneath the kitchen window and gave him the left over Ambrosia - surely something he had never tasted before and I'm more confident it was Halal.

Hectic Friday night entertainment - "Pick-up-Sticks"

It was International Women's Day on March 8th. I would have liked to have organised something in the village but there wasn't the time. I celebrated it by watching Bridget Jones' Diary then asking a man to come and dispose of a dead chipmunk in the garden because I was too afraid. Girl power.

Hamna hela and a little bit of hatari*

*No money and a little bit of danger

My first hint of danger - I made the mistake of leaving the town of Masasi too late, on a dala dala so wrecked you could see tarmac through the chassis. After 90mins the driver decided he wasn't going any further. It was dark, I didn't know where we were, and bus stops here are yet to install the digital next bus is due in XX minutes announcers.  After waiting at what may have passed for a place where buses could be hailed, the village got wind of a mazungu in their midst and before long 30+ men and children were enjoying the Saturday night spectacle that a stranded mazungu provides. Piki-piki drivers offered me rides back to Nyangao but I didn't fancy getting on the back of a cheap Chinese motorbike after dark, with a potentially drunk driver, on roads where you could disappear up to your neck in a pothole. People were trying to tell me there were no more dala dalas but I suddenly suspected everyone of trying to trick me and rob me of the papaya and Grade A cashew nuts I had in my bag. I'd lost the ability to understand a single word of Kiswahili and no-one spoke English. I buckled and tried to ring someone with a car to come and rescue me but there was no phone signal. I was one more drunk man away from crying like a baby when I weighed up the options and decided to trust the 3 guys who said I needed to leave the village and walk down the unlit highway to a makeshift barricade 200m away. From here I would apparently be able to get a ride. I headed off into the dark leaving the throng behind me with my 3 companions who turned out not to want my papaya or nuts. At the cordon, the lights of a dala dala appeared out of the darkness and with huge relief I climbed on-board before they could fully open the door. I have never been so happy to see the familiar Nyangao sights - the dead Baobab tree, the intermittently functioning Vodacom tower, the tatty plastic tables at the Old Trafford pub (which was in darkness again after another power cut). 

The outlook over Masasi

Prior to the adventure getting home, the trip to the scruffy crossroads town of Masasi was fun (ref: pg 192, The Rough Guide 3^rd ed). It was like visiting Waitrose after only shopping in Asda. We toured a corosho (cashew nut) factory and saw the labour intensive process involved in getting the nuts ready for sale. Sheds full of women shell coroshos manually, their fingers covered in flour and oil to protect the skin from the toxic substance inside the shell. The flour and oil is not enough to stop them developing chronic eczema and then later possibly skin cancer. The older ladies were given jobs that let them sit on the floor - sifting through the discarded shells for the tiniest pieces of nut that could be turned into animal feed.

The new recruits' uneconomical attempt at shelling

I also feel safer this week as one of the village schizophrenics is an inpatient at the hospital. Ward 1 is going through absurd amounts of chlorpromazine and diazepam but at least the cameraman, as he is affectionately called, is not wandering the village. Usually good-natured, the cameraman has recently started attacking women. He lost the broken camera he always carried around his neck a while ago - around the same time he suffered a beating and black eyes but he keeps his nickname so we can differentiate him from the other schizophrenics.  During the Sunday Service he always used to sit on one of the altars, but since he beat one of the choir members last week, he hasn't been seen in church. Hopefully he will be transferred to the one and only psychiatric hospital in Tanzania but if his family can't afford the costs, that's unlikely to happen.

Patients on the TB ward at Nyangao

The hospital is otherwise quiet at this time of year. There are fewer patients in the wet season because there is less food available so the little money people have they spend on keeping their families fed rather than getting diseases and broken bones treated. More time than usual is spent lolling outdoors on benches chatting with other hospital staff or going nje to chat to people outside the hospital walls. "George, wapi?" (Where is George?) "Nje" (He's outside). "Andreas, wapi?" "Hayupo" (He's not here). It's trickier than usual to track down one's colleagues at the moment. The hospital has run out of money too. Today a notice went up explaining that no-one could be paid February's salary. Nobody knows when they will be paid; there may be no money for several months. More of my colleagues than usual are telling me they're hungry, indirectly asking for money, but I won't collect my VSO allowance until they get theirs. Before long, I imagine more and more staff won't turn up, going to work on their shamba (farm) rather than at the hospital. Everyone has more than one job here. I bought Baba Hamsa the askari (guard), a bottle of chloramphenicol eye drops because he had no money to see a doctor or pay for medicine to treat his eye infection. It only cost 40p but that's 10% of my daily income and a much greater proportion of his. In return he brought me some custard apples. He pinched them from the tree in James' garden so I don't feel so bad that he spent his little remaining money on me - they were the first and best custard apples I've ever had.

Proud shop-keeper at the market

TIT: This Is Tanzania

Some Tanzanian miles have been covered in the last month. Back from 2 weeks in the big smoke, Dar Es Salaam, for VSO training and language lessons. I'm now equipped with what to say if the police ask for a bribe; I know it is rude to smell food before you eat it; inappropriate to hang your underwear in public view; bad manners to blow your nose or pass wind in company; culturally insensitive not to greet people and ask after their home, family, children, work, chickens, farm so on and so on. I also have a better idea of what I am here to help do. Incidentally, this is to ensure one million women and children have better access to health services and that mother and child mortality is reduced by 50%, by the end of 2015. It so happens that I am only here until the end of 2014, which kind of relieves the pressure on me somewhat.

It was much fun meeting the other new volunteers.  Eating out, shopping, getting on buses with 30 pale-skinned, wide-eyed new arrivals; nothing like a large group of wazungu to draw attention.  Once everyone had arrived from Canada, the UK, the Philippines and the Netherlands, we made the 3 hour journey north-west to Morogoro, at the foot of the Uluguru Mountains for 4 days of Kiswahili training.  Morogoro is one of the few places in Tanzania outside Zanzibar where women wear burkas and it has the largest munitions factory in East Africa, a legacy of the town's role as a major base-in-exile for South Africa's ANC, whose cadres were trained in the mountains.  Thanks for the heads-up, Lonely Planet.

We stayed in luxury accommodation (for Tanzania). Kiswahili lessons finished by 3pm at which time we were free to do our own thing or were sent off into town on language exercises. These consisted of conversing with the locals as far as possible which we usually finished after a stressful 15 minutes of faltering over saying "hello, how are your chickens?". I am sure the locals appreciated our retreating to a bar which meant they wouldn't have to endure yet another group of students who turn up in their home town every few months with nothing to say but "How old are you?", "Do you have children?", "What do you like doing at the weekend?"

Four days of being cooked for, cleaned up after and peered at by (yet more) nuns, lessons were over. Sadly not fluent but the money for teachers had run out.  Our entertainment committee organised a quiz. My favourite question: "How many Americans had their brains mutilated in mental institutions between the years 1935-1965?".  It was a tough quiz. "Not enough" wasn't one of the optional answers. Some of the more energetic group members absconded to a local nightspot where there was a live band and vigorous performers. It was refreshing to see that in Tanzania, women who have clearly given birth more than once are comfortable bumping and grinding on stage.  They kept us dancing until 1am by which time we had been locked out by the nuns and had to wake up the unimpressed watchman to let us in.

Walimu wetu (our teachers)

The driver of the bus on the way back to Dar Es Salaam made us write our names down on a piece of paper. Turns out this was in case there was a bus crash the police would be able to identify who was on-board.  We weren't asked on the way to Morogoro because the bus was "too busy" - I guess you have to keep your fingers crossed there will only be an accident on the way home.  TIT.

A few more days of making the most of the company, food variety and pirate dvd shopping opportunities and it was time to return to the village. As is often the way, the trip home was prolonged when the driver who picked us up at the airport to drive the last 150km, took us back to his own home whilst he had his car serviced.  We ended up staying for breakfast, then for lunch and eventually left 5 hours later, experts at using a squat toilet. TIT.

I miss being in the company of 30 other people all the time. It's not the same talking to yourself or fan-bathing alone, a past-time my roommate and I invented after a particularly hot, sweaty day. It requires lying on your back in minimal attire directly underneath a ceiling fan. Once the front side is perspiration free, turn on to your stomach to dry the rear.  Repeat as required.

So back to the grind of life in Nyangao. Today one of the pharmacy staff asked me if she could take home a used printer cartridge I had thrown in the bin, to give to her children to play with. The children here are pretty resourceful. I've seen more than one pulling a plastic bottle behind them that has been fashioned into a vehicle of some sort, complete with bottle lids for wheels and pebble passengers. Must bring back some Hot Wheels on my next trip home.