Yesterday after nightfall I was called to the labour room for a patient having her first baby. She was two weeks overdue, confirmed by early ultrasound, and labour had been induced by misoprostol, a uterine stimulant given orally. After 48 hours she had reached 5cm, the contractions were poor and the baby’s head was 4/5 above the pelvic inlet. We decided it was time to do a Caesar.
On hearing this, the mother of the girl stormed out of the room loudly announcing her displeasure. “Anasema?” I asked, “What did she say?” “She said, ‘she has been suffering since the day before yesterday and you wait until now!’ “If I had a telescope that could see the day after tomorrow maybe I could have done it sooner!”
I went to prepare the operating theatre while the staff prepared the patient and then the power went off. It was complete darkness. I didn’t see that coming either.
The power kept coming and going. The patient entered the theatre in the light and lay down in the table in the dark. She felt sick and vomited in the light. I cleared it up and washed the floor in the dark. Someone came in with a torch. Another staff member started the generator and we were able to proceed and all went well. A healthy baby boy and a good result for the mother.
Trusty generator
Not so good for the patient who had a Caesar two days earlier. She had one previous child by CS and is now very overweight. She travelled many, many miles to deliver in our hospital because her relative works here, bypassing a well equipped hospital with a good reputation. She went into labour at 37-38 weeks.
At operation, delivery of the head was extremely difficult and delayed. The baby was resuscitated and went with the mother to the ward.
The following morning he failed to feed at the breast and had breathing difficulties. Probably Respiratory Distress Syndrome but he was treated for infection as a precaution. Antibiotics, a bronchodilator and steroids were given through a jugular vein but he remains very sick.
Yesterday he was to be transferred to our Regional Referral Hospital 120 km away, half of that on rough roads. The cost of transport there by hospital car is 300,000 Tanzanian shillings, about £100. Two weeks’ wage for a hospital worker.
The family deliberated all day, another long delay for a very small sick patient. How do we know if he will survive? He may not even reach there alive and that is a waste of money.
He is still with us this morning. The family have been counselled – his chances are 50:50. They are calm.
If they had only known, would they have travelled to Milo rather than Peramiho? If I had only known, would I have cut the abdominal muscles to get the baby out sooner?
If only.
If we had the benefit of hindsight beforehand, what a difference that could make…
With thanks to Tulula of ‘Bugsy Malone’ fame for the title…
Back in the Southern Highlands of dear Tanzania I have plenty of time for reflection as I am alone.
Hilary and I were here for 5 weeks in January 2025. It was a deliberate short visit. I had several blood transfusions during 2024 and one just before we left the UK in Jan 25. I had no idea how quickly my haemoglobin level might fall and having a transfusion in East Africa would not be my choice. Blood is precious and I would be uncomfortable using any from so limited a supply. The blood is screened for transmissible diseases but I would not choose to risk local viral or parasitic infections.
We returned to UK to find that the blood count had not fallen during our time away. Living in a warm place at altitude had kept the level up and amazingly I have not had another transfusion since that time. It’s been over 12 months now.
Armed with that confidence and encouraged by my haematologist to escape the British winter of at all possible, I said goodbye to friends, family and wife and flew on 1st January just as snowstorms were being forecast for the UK. Flying Manchester to Dar with Ethiopian Airlines via Addis Abeba I arrived in the hottest time of year.
My visa was scrutinised by Immigration Officers more than my baggage by Security and I had no duty to pay on surgical instruments donated by medical friends in UK.
The onward journey to the regional town of Njombe involved 15 hours overnight departing Dar at 6pm in twilight in the company of Debbie, the courier of the Ultrasound machine which returned to UK and the Netherlands for repair and refurbishment in autumn 2024, and her adopted young Maasai, Laizer.
Laizer & Debbie before the overnight bus ride
We survived the journey which consisted of three legs each of 5 hours overnight departing with two stops of 10-15 minutes. Laizer slept full length in the aisle of the bus while the only two white persons dozed fitfully in their seats.
The hospital Landcruiser was already in Njombe on other business and waited to take us to the village.
After a comfortable night in the new hostel built by the Anglican Diocese in memory of Miss Eira Lloyd who had been headmistress of a school in Zanzibar before retiring to live in Milo village for several years, we were driven the 120 km or so to arrive late evening to the usual welcome of a ready meal.
We paused partway on that journey in Luponde to greet Edishen and Catherine and their new twins, staff at St Luke’s Hospital a few years back and now in a new location.
Laizer, Catherine, Dr Benedict, Edishen, Dr Adrian, Debbie and twins at Luponde roadside.
Once in Milo Debbie was delighted to join the ultrasound outreach team in the nearby village of Mavala to observe in action the US equipment she had so kindly carried to and fro to keep the program going. She and Laizer departed on other business after a couple of days and then back to UK.
This week the senior hospital team have together left for a medical updating conference in Iringa 200km away, MO in Charge, Matron, Senior Midwife and Pharmacist. So I am alone in the house, the only surgeon, the only white person in the village. But it’s not as bad as it seems. I have generous meals made from local produce. Plenty of banana, mango, papaya and avocado. Rice, beans, chapatti, eggs, tomatoes, potatoes, green veg, chicken, (rabbit and guinea pig not yet sacrificed), beef, pork, tea, filtered water. Comfortable bed, shower that works but floods the bedroom (thankfully the whole house has a concrete floor) and European toilet!
In my spare time I’ve started collecting litter from the approach roads to the hospital. The hospital grounds are well kept by the staff I’m glad to say. Small school children on the way home stopped today to help me. There is so much discarded plastic.
The litter goes into the hospital pit to be burned and buried
My good friend John watches out for kipepeo since he has observed my obsession with butterflies and moths. I have tried in vain to teach him not to pick them up by the wings. He thinks they will bite. This evening with great excitement he took me from home to the OPD to see the latest specimen. What a huge and beautiful moth!
At last John trusts me – they don’t bite!
I have written enough for one day. Bear with me. I’m very pleased to have recovered my Blog after a long struggle with passwords and other rejections.
I have had great trouble using WordPress for some reason and this is yet another attempt to post.
I wrote the following message from Tanzania in January 2025. If I am successful this time I hope to continue to update the Blog until my current visit to Tanzania, January 2026.
“A whole lot has happened since my last post in December 2023. We returned to UK for Christmas to a cold Manchester Airport still taking anti-malarial drugs to complete the protection. Not needed in the village above the mosquito zone, we only take them as we travel overland to Dar es Salaam and for the required weeks afterwards. Mefloquine is taken once weekly and I took my second dose in UK. The day following, my urine was as black as Guinness or Coca Cola. It was the Saturday before Christmas so I faced a number of days without access to medical investigations except that my GP reopened his surgery Saturday afternoon to see me. With the urine testing strongly positive for blood empirical treatment for schistosomiasis was advised and on enquiry to two North Wales hospitals one course of the appropriate drug was located in the pharmacy of one hospital an hours drive away. The on-call pharmacist came in to open up his department and provide the drug after I drove there Saturday evening. What an amazing service and kindness from these helpful people!
One week later the same happened after mefloquine – black urine for 24 hours. Before January 2024 was out I had full haematology investigation including CT scan and bone marrow biopsy which revealed Cold Agglutinin Disease – CAD for short – a form of autoimmune haemolytic anaemia due to underlying low grade marginal zone lymphoma. There was no clinical or CT evidence of lymphoma in liver, spleen or lymph nodes.
A tropical medicine consultation ruled out any other possible infective cause. The management now is to avoid cold at all costs – the antibodies are activated by exposure of any part of the body to temperatures below about 7 degrees Centigrade; blood transfusion if the haemoglobin falls into the low 70s (significant anaemia); if possible live somewhere warmer during the British winter and, if this means returning to tropical climes, avoid malaria at all costs. So here we are in January 2025, after several blood transfusions last year, now back in Tanzania visiting friends and to check on sponsored school children and the hospital in the Southern Highlands, especially the ultrasound outreach program.
The US equipment had developed a couple of faults in 2023 so we had it brought back to UK mid-2024 and sent it to the manufacturer in the Netherlands. Several unsuspected faults were rectified and a replacement probe provided and, oh joy, it was still under guarantee, and is now as good as new! Our friend Debbie who acted as courier for the machine generously agreed to take it back to Tanzania in October and the outreach to pregnant women was resumed after just 6 weeks.”
It is a long time since my last blog and I owe an explanation and have a backlog of information to share. We are back in the country for a five week visit which is drawing to a close and during this time I have been struggling to access WordPress on the laptop and iPad. I think I have a password at home that I needed here.
Here I am on the mobile phone (at last) having returned to Dar from the village of Milo, due to fly out tomorrow, recovering from the long drive which we broke down into four separate days, being more manageable at our age.
I have always enjoyed driving here – especially the challenge of the red dirt roads where ‘off roading’ is not something you seek and pay for as a Red Letter Day adventure but the everyday means of travel from A to B. But the long journey from the village of Milo, north and east to Dar es Salaam, is losing it’s glamour, if it ever had any.
As far as pot holes are concerned, these days it is not much different from the UK (aside from British motorways). There are large holes everywhere and vigilant avoidance is essential even for the drivers of big trucks which spend a great deal of time on the wrong side of the road in some stretches, avoiding the holes and broken areas along the road margin, and ruts in tarmac which is too soft for the ambient temperature and on too flimsy a foundation.
These trucks are a problem. They are far more numerous than they were a few years ago and tend to aggregate into long trains of anything from half a dozen to 10, 12 or more. For some inexplicable reason, the white lines in the centre of the road favour overtaking downhill rather than up hill where the trucks are climbing at 5 kph in their lowest gear; here the double white line is contrary to overtaking them. In the UK it is legal to overtake a stationary or slow vehicle on double whites if the way is clear and visibility good. In Tanzania there seems to be a police presence at the top of every such climb waiting to pull over any vehicle that attempts it. I have lost track of the number of fines we have paid over the years driving here for that particular offence. Despite protestation, I have not been able to persuade the traffic officer of the common sense necessity of my manouvre.
The Polisi are usually very polite, exchanging greetings being part of Tanzania culture, and I always express my sorrow at their work when I have been stopped (“pole na kazi”) and wish them well at their work on my departure (“kazi njeema!”). ‘Pole’ by the way, is not pronounced like an eastern European or the means of flying a flag; in Kiswahili it is ‘pol-ay’ and means sorry, but ‘pole pole’ means ‘slowly’, don’t ask me why.
And that reminds me: half the fines we get are for speeding. In any village we pass through the limit is 50 kph but half of the 50 signs are missing or fallen over and one is supposed to know where the limit starts and ends. Difficult. I argued with one traffic officer brandishing his camera ‘gun’ showing my 80 kph violation of the 50 limit, that there was no 50 sign at the top of the hill I had just descended. He insisted there was and I insisted there wasn’t but he issued the ticket regardless, and I decided it wasn’t worth expending any more breath or wasting any more time on £10.
Kazi njeema!
The fine is 30,000 Tsh, these days issued with a portable ticket machine like a card reader which reads a driving license instead of a credit card, and must be paid within 7 days. There are ‘Wakalas’ everywhere: small booths on every street where money can be paid (or obtained) using a mobile phone. We hand over 30,000 (£10 equivalent), the Wakala texts it to the Police using a control (reference) number on the ticket and almost immediately a text arrives on my mobile phone confirming the payment. Very easy and no longer any possibility of cash payments at the road side ending up as the Polisi Christmas Fund or whatever.
Pretty well every long journey involves two or three fines. It’s a bit like travelling on a toll road and a chance to practice Kiswahili on the way. And there are no points on the driving license, otherwise I would be banned from driving within a couple of days, and so would half the population here. These days there is a website where one can enter the vehicle registration number and see if there are any outstanding fines and so pay them before the seven day deadline. Parking fines appear there too, and have a longer period of grace. More advanced than the UK, methinks.
On overtaking trucks climbing a steep hill, here’s a tip: drive near the white lines so as to see to the crest of the hill. If a truck at the top of the hill pulls out to overtake another, the road beyond him is clear and I can pull out and overtake too. But, while concentrating on the road ahead and seizing a chance when it presents, I must not forget to check the mirror. Yesterday a loud air horn blasted my right ear as I started my overtake. The truck behind me had seen the opportunity too, and was already halfway alongside me. He braked, I swerved, the truck I was overtaking was just out of reach and I avoided both by a very narrow margin. Thankfully. In my mirror I could see the would be overtaker stationary on the wrong side of the road trying to get moving again and rejoin the line of trucks on his left. “Pole sana”, my fault, I wish I could say to him, but too late.
Always check the mirror
There is a notorious steep road between Iringa – a lovely town in the hills – and Mikumi on the edge of the wildlife park of the same name, where trucks travel just as slowly downhill as they do uphill. They descend in low gear to avoid overheating the brakes and to ensure they are in control should there be a brake failure. It is a mountain pass really, with many bends, climbing from the plains where the road transects the park where the impala, giraffes and zebra graze and baboons beg from passing buses, eventually to reach Iringa.
No overtaking is allowed anywhere on this hill and there is a constant police presence, a good place to fill the coffers of the government police fund or whatever. Bus drivers always overtake here. They overtake everywhere. Rival bus companies compete for the fastest time on every long distance route and, at times, for extra passengers on the way. As we descended that road yesterday, the cars as usual hopping from space to space between the heavy lorries, we picked up another fine for overtaking. Further down the hill was a log-jam where an articulated lorry climbing up had given up the ghost. Behind us on the descent was another artic whose rear wheels were smoking due to overheating brakes and, behind him, two or three petrol tankers. In my rear view mirror I could see the smoke rising despite the fact that he had stopped. The driver got out to look at his trailer but found nothing he could do and climbed back into the cab. I decided to overtake again as soon as we passed by the stranded artic to put some distance between us and the possibility of a trailer on fire and a bunch of petrol tankers. Worth another £10 to get out of there for sure.
We refueled in Morogoro, a big town well beyond the wildlife park on the way to Dar. The manager of the fuel station pointed out to me a soft front tyre but their air hose was broken. We drove next door to find a Wakala to pay the latest fine and the manager followed me on foot to show me another facility with an air line where I had the tyre reinflated while Hilary invested in the Police Fund. The guy then showed us where the toilets were on his garage site without being asked. He could see we were strangers on a long journey (not difficult as we saw no other Mzungus all day) and showed us great kindness. I thanked him and wished him God’s blessing, “Barakiwe.” “Amina” he replied, ‘amen,’ a kindred spirit.
Thank God for such kindness and hospitality from this wonderful country and its lovely people, even the Polisi.
The past week has had rather more drama than one would wish for. Today the closed road to Maholong’wa has prevented the weekly Wednesday outreach ultrasound program and provides a welcome respite with time for admin and blog.
Last Wednesday the outreach to Ludende ended early afternoon just as the rain began. On the way home we stopped by some bamboos to collect leaves for the guinea pigs, which they love. Nurse Ezekiel clambered enthusiastically down the steep hillside below the car filling his arms with foliage. I took an phone call from Matron. ‘Please come, the patient you saw this morning has collapsed.’ I had diagnosed an ectopic pregnancy and had requested blood intending to operate later.
‘Ezekiel! Njo!’ ‘Come quickly!’
The rain increased as we drove through Masita and up the hills towards Milo, sliding on the wet clay road on the hills and the bends with head lights and hazards flashing entering the hospital compound 20 minutes later, sounding the horn.
Theatre was already prepared. The patient soon asleep and the ruptured left fallopian tube was clamped and the bleeding controlled. Two units of blood were forthcoming despite the rain – the motorbike courier braves whatever weather is thrown at him. Ectopic pregnancy is one of the top 5 or 6 causes of death due to pregnancy complications. Sometimes not recognised in time. The fetus in the tube is extremely small of course. The rupture which causes intra-abdominal bleeding is really a dangerous form of miscarriage. There is no hope of rescue of such a misplaced pregnancy.
Two days later we admitted a young woman 32 weeks pregnant who had been hit by a motorcycle while walking on the roadside in a nearby village. Her abdomen had taken the impact and she was in pain and her abdomen bore the scar of a previous Caesarean delivery. Her vital signs gave no cause for concern for her own safety but the fetal heart rate was very rapid. The baby was very possibly injured yet to deliver a premature baby with no incubator or facilities to treat the newborn would be unwise. The safest place for recovery is inside the uterus.
Sadly, by the following morning, the baby had died. The quandary now was how to deliver. If the impact had killed the baby, the uterus could well be damaged also and the stress of labour could rupture her Caesarean scar. We had no alternative but to operate, deliver the baby and inspect the uterus. We found all to be well with the mother’s internal organs and the uterus was repaired in the usual way with Caesarean delivery. No external sign of injury to the baby was found and we concluded that head injury was the most likely explanation for its demise.
Prosper, a determined young village boy living in poverty with cerebral palsy, friendly and turning up everywhere. A special member of the community, sometimes intrusive, with no boundaries, born with challenges but a survivor by nature…
The weekend saw the arrival of a woman in a collapsed state with a record of three previous Caesars, now due for her fourth operation. She had remained at home for a number of hours before her relatives brought her to us in profound shock. The baby was already dead in the uterus. Two intravenous infusions were established, theatre prepared and blood requested from our nearest hospital neighbour two hours away.
I prayed that her bleeding would be uterine not a ruptured splenic artery aneurysm or other rare disaster. Blood poured from the abdomen when opened. The cause was immediately apparent. The placenta had invaded and completely penetrated the uterine wall. It was not necessary to make an incision in the uterus to deliver the baby. I pushed my hand through the placenta to grasp and deliver the baby, cord and placenta in one action. Clamps applied to the uterine wall and major blood vessels partially controlled the bleeding while my assistant compressed the aorta against the mother’s spine. He maintained that pressure for well over an hour until hysterectomy was completed. We gave three litres of iv fluid during the operation. The blood arrived during another rain storm around four hours later.
Urine was pouring into the catheter bag, reassuring us that the kidneys were still functioning despite her shocked state from haemorrhage and that the ureters had escaped surgical injury (a hazard in this kind of emergency procedure) and that fluid replacement was keeping pace with her blood loss for the time being. We had only two units of blood and these were transfused over night.
By the morning her face and hands were swollen suggesting that there was more ‘water’ in her circulation than blood. Our district hospital could supply no more so we turned to the Catholic mission hospital 2 hours in the other direction. They had 1 full and 1 half unit of compatible blood which was duly dispatched in our direction, transport cost 40,000 shillings – about £12. That extra blood made all the difference. Her pulse rate which had been 140 when we operated and had remained over 120 all night, now fell below 100 and we felt she had turned the corner.
On the second day her haemoglobin level was 10.4, pretty good in the circumstances, and she got out of bed and sat in the afternoon sunshine outside the ward.
Today is day three, Wednesday, th evening of the cancelled clinic. I have seen one patient today and recovered from the dramas of the week. Thankfully these three mothers have also recovered despite the sad loss of their babies. Maternity care in truth is mainly routine and controlled normality but the emergencies can be sudden and stressful for all. Staff and patients alike need recovery time. Today has been one of those most welcome times.
A special bird, lovely personality, calm and efficient layer, a real star…
Postscript: Saturday 9 December. Since I wrote this report the hospital has been quiet in outpatient, ward and theatre. There have been admissions, operations, discharges and even deaths but no dramas. We ‘Spring-cleaned’ the house in preparation for leaving next Wednesday. Our car is still immobile and waiting for engine parts. The hospital car has been put at our disposal for our journey to Dar. The guinea pigs, doubled in number, will be returned to the nuns of Sayuni. The hen, who continues to lay one egg per day, will remain in Milo under new ownership. Perhaps there will be another blog before we leave the country… we shall see.
As a change from a male medical perspective on life in a Tanzanian village hospital, it is time to hear the voice of Hilary, my wife and constant companion who has her own role and viewpoint. I combine here two of her recent writings to friends in UK:
We have realised that in our letters/blog we often focus on the difficulties rather than the positives because, I think, they make exciting reading. We then receive praise for coping which I don’t think we deserve! Our life here is tranquil – no traffic, very few planes passing over and very high and silent, just birdsong, the wind rustling the grass and trees and distant voices of people working in the fields. Even in the hospital it is quiet and women in labour make no sound although there is no pain relief. Babies are contented and rarely cry. Children chatter in school and football matches are noisy! Church services are noisy with singing, praying and the preachers are vociferous!
At night it is inky black unless the moon is waxing and the myriad of stars – a few Northern hemisphere constellations that we know (Orion is upside-down) but many Southern Hemisphere constellations that we do not know.
Nothing is done in a rush and time does not exist. People and relationships are the most valued. If you are walking to a meeting or to work and you meet someone who greets you, you stop and talk. Every encounter starts with a greeting to you, your family, your home and is never hurried. It would be the height of rudeness to make the excuse of an appointment even if it means you are “late”. Tanzanians are unfailingly polite, kind and courteous and one has to learn to slow down and behave culturally appropriately.
It was shocking and embarrassing to hear that an English priest who had a personal vision to build an orphanage in this diocese and one building is complete, visited two weeks ago to check on the progress and because it was behind her expectations lost her temper and was extremely rude to the bishop. Humble man that he is, he went with some volunteers and was on his knees painting the floor with them the next day. The English priest is demanding and particular about every detail insisting on Western facilities rather than conceding to local practice. She has now washed her hands of the project and once this first phase is complete is to hand it over to the bishop. No thought given as to how to sustain it! It’s like the worst of colonialism! I can’t understand this attitude. People have lived here for thousands of years and if there was a global meltdown I would rather be here where respect for and dependence on the land sustains life.
So our life here is relaxed (unless a medical emergency), quiet and peaceful. We have plenty of food, a comfortable bed and chairs, outstanding views, kind and generous friends and colleagues and at the moment sun and therefore solar power! It is definitely not a sacrifice to be here. 😍
Moonrise from our back porch
It’s been a busy week for Adrian at the hospital but I gave my last English lesson this week so I can concentrate on hospital admin for the next two weeks. The Standard VII results came out this week (the leaving results from Primary School so they can progress to Secondary School). Milo came first in the “Ward” of 5 schools locally and all but two passed. However English results were poor so I don’t know how they will cope in Secondary School where subjects are taught in English. Unless children go to a private English medium Primary school, English results are universally poor. To succeed they have to be fast learners of English. We buy subject text books for the sponsored students to give them the best chance.
Adrian did the Amani clinic yesterday with only a nurse as Dr Sandagila had to attend meetings in Dodoma this week. They arrived 10.30 having been delayed by a closed road and having to return and divert. He saw 54 patients in 12 hours without a break leaving at 11pm and arriving back at 2am 😲. Then he saw two labouring patients before bed and is seeing patients right now. He will be glad of a break when we get home!
Road closed with heaps of soil without warning
On a better note, refurbishing of the female wards has begun and the gynaecology ward is complete with fully tiled floor and repainted inside and out. It looks really bright and fresh. I will take some photos. Work is starting today in the maternity ward and labour room. I would still like to do more in the labour room to get new beds – one is propped up on bricks! But for many patients, this is much better than they have at home of course. Patients come from a considerable distance away because they trust staff at a mission hospital more than at government hospitals (and of course especially when the white doctor is here 😉).
‘Take care’ became the maxim for Covid and continues to be good advice. More relevant to my current context is the prevalence of HIV, with 11.5% of our maternity population testing positive in the five years 2018-2022. One in every fifteen of our first time teenage mothers tests positive.
An 18 year old tested positive around 2 months before her baby was due but hid the fact from her family and did not accept treatment for several weeks. Inevitably the risk of transmission to her baby was high, and so is the risk to staff involved in her care. To reduce the chance of her baby acquiring HIV, delivery by Caesar followed by immediate preventative anti-retroviral (ARV) drugs is essential. She also tested positive for syphilis which she can transmit to her child and attendant staff.
There is a lot of blood and other body fluids spilled and splashed during Caesarean delivery. There are visors available to protect the eyes but I have rarely seen them worn here. That’s something we can do better. Two pairs of gloves are worn. Needles are handled with instruments rather than fingers. Care is taken to avoid injuring the surgical assistant with the needle. Sudden and unpredictable movements during surgery are avoided. Puncturing the membranes may spray liquor especially if coincident with a uterine contraction. Planned CS before labour avoids this yet everyone stands clear nevertheless. Cutting the umbilical cord may spray blood and the cord is milked dry between clamps to prevent this and a swab may be used to cover the scissor blades.
Surgical blades and needles are disposed of in a ‘sharps box’ (but the box is emptied and reused). Surgical swabs, gowns and drapes are laundered, sterilised and reused. The placenta is disposed of in a ‘placenta pit’ in the usual way. Other materials are incinerated. Everything is done with great care but also with an eye on the cost.
The Placenta Pit
Twice I have taken a month course of PEP – post-exposure prophylaxis – and I prefer to avoid taking it again.
In this case the baby boy was in good condition at birth and started his nevirapine and erythromycin immediately. He will be tested after a month of ARV to direct further management.
Tanzanian culture and especially rural communities like ours are naturally very caring in many ways. Noah was preparing to burn the wheat field by our house before planting maize and kindly warned us lest the guinea pigs suffer. They were evacuated in cardboard boxes until the smoke died down. Noah frequently brings bamboo leaves and other greens for the guinea pigs and latterly the remains of crushed sugar cane which they love. I hope that their life span is too short for dental caries and diabetes.
Burning the shamba
I discovered maize cobs on the hen house roof left by our hospital cashier who noticed I had no feed for them. The hens may lose weight and fail to lay if ill-fed but their days are numbered as they are destined for the ‘pot’.
Three boys rescued from the smoke.
A week after the burning of the shamba the whole area was turned over by hand and planted with maize, also by hand. It is good practice to rotate crops, in this case maize followed the wheat. On Sunday there were special prayers of blessing for the planting. This is new for us who are familiar only with harvest thanksgiving.
Martha, hospital cashier, planting maize
Having prayed for the planting season, our priest made known that his season for moving on has arrived and next weekend will be his last in the village. He will move with his family to another parish, Makete, around 150 km away. Jesus’ teaching about spiritual planting and harvest drew on everyday events which are still current here.
In this world we are so very dependent on things and stuff are we not? Yet we like to be independent and tend to avoid dependence on other people and at times may forget that we depend on God for life and mobility and our very existence.
The car gave out a full month ago, since when it has been stranded in the hospital courtyard. We are waiting for a new nozzle to deliver diesel to one engine cylinder. Thankfully the hospital car (which towed us home) is still going and the ultrasound/antenatal/medical outreach clinics continue. We are into the season of ‘little rains’ when reliable transport is more important than ever.
Since we arrived in Milo, due to the dry season and low water levels in the dam supplying the hydroelectric power station, we have had electricity only at nighttime and weekends. The laboratory fridge could not be kept cold to preserve essential reagents and certain drugs. Three weeks ago two high capacity batteries were installed to charge overnight from the mains and to run the fridge by day. No sooner was this completed than the mains electricity failed due to a problem at the hydroelectric power station that supplies our area. Spare parts have been ordered from Italy. The last time this happened we had no power for 3 months. Our own solar system (in the house – not sun, moon and planets – you understand) failed and a new controller was supplied and fitted. No sooner was this achieved the little rains began and the days have become intermittently cloudy, totally misty or wet. Throughout the villages but more importantly in the hospital it has become challenging to maintain charge in mobile phones, laptops, torches, pulse oximeters, ultrasound, etc. Everyone is seeking places where there is some battery power to be had. At the same time the connection from a portable emergency generator that supplies the operating theatre burnt out and we cannot find a suitable replacement. We have no lights nor oxygen concentrator. We are trying to keep head torches fully charged through solar. These are invaluable and powerful but, being LEDs, they do not fade when they need charging. They go out instantly which would be dangerous during a night time Caesarean, and we have had several of late. So we must keep them fully charged and not use them for any other purpose.
We travelled to Mapogoro dispensary last week and saw 51 patients. Being carefully selective we scanned only 24 of them and managed not to run out of battery life. It was misty and wet on the journey, very challenging on these roads in the hospital car whose heater and blower do not work, very difficult to see through the windscreen and avoid the ruts and holes.
Meanwhile we discovered that one of the hospital wards without light is now supplied by the battery removed from our stranded car and hooked up to a solar panel which charges it by day, while it runs the ward lighting by night. In this way the battery will not go flat through disuse and the car serves a useful purpose despite its immobility. Necessity is still the mother of invention…
Last night we had another repeat Caesar admitted in labour three weeks after the date she should have had a planned (daytime) operation. It was extremely difficult with one headlamp, one mobile phone and a tiny cheap solar lamp with fading battery. There was much scar tissue and adhesions preventing access to the uterus and baby. A large portable oxygen cylinder supplied by an NGO, but without a key, could not be opened. We are very dependent on God in these situations and pray openly as we work, surgeon and staff alike. Desperation drives us to prayer. Sometimes anger drives us to pray. Why did this patient wait at home for 3 weeks when the due date for her Caesar was clearly defined after two scans? Why did she come in the dead of night in hard labour with her tiny elderly grandmother, the only relative available to care for her immediate needs and those of her newborn baby? Why must we be up at night operating in such difficult circumstances when every effort is made to plan and conduct these operations by daytime? And still, we praise God that he delivers us and our patients time and again.
We delivered a premature baby by Caesar the previous night, 1.8kg, seven weeks before the due date. If such small babies are allowed to become hypoxic or cold their survival chances are much reduced. If delivered vaginally, best practice is to dry and stimulate the baby and wrap it in skin to skin contact with the mother. This maintains body temperature without the risk of cooling or of overheating by using a hot water bottle (not the flat rubber kind, but a discarded 1.5 litre plastic bottle wrapped in cloth). At Caesar we cannot put the baby in contact with the mother – she is anaesthetised, cold, lying in blood and liquor, and after suturing will be washed in cold water as we cannot use the kettle. In this case a relative was sought to whom the baby could be bound for warmth. Fortunately this patient had more than one, for the first relative was very cold to the touch! After dark, in the rains, the temperature tends to fall rapidly and we have again resorted to log fires in the house. The hospital kitchen is the only place relatives can find a (cooking) fire by which to warm up.
So there are many challenges at the moment through which we press on, doing what seems at first impossible, powerless but relying on one another and on God in whom we trust and on whom we depend as never before.
This lily blooms in our garden here, once a year, for a few days only. ‘Consider the lilies,’ said Jesus, ‘transient as they are, your Father clothes them with beauty. How much more does he care for you?’
The UK Abortion Act of 1967 was introduced to protect women from the consequences of backstreet abortions. Deaths due to unsafe abortion, and other less serious complications fell dramatically following this legislation. An unintended consequence was that abortion became generally available on request as the law can be interpreted very liberally.
Induced abortion is illegal, severely restricted or socially unacceptable in many countries including Tanzania and unsafe abortion is practised and remains one of the major causes of death associated with pregnancy.
During our three year stay in Tanzania a young female patient in St Luke’s hospital with peritonitis was transferred to the Regional Hospital but died soon afterward. It was recognised too late that an attempt to terminate her pregnancy had perforated her uterus and damaged the bowel and patients and their relatives are reluctant to admit to intervention of this kind.
In the past week two cases of unsafe abortion have been seen in the hospital. The first came alone by motorbike taxi with severe vaginal haemorrhage. Her haemoglobin was 3.1 g/dl, 25% of the normal level. Her uterus was emptied by manual vacuum aspiration (MVA) and the bleeding was controlled. The products of conception smelled really offensive. She was treated with the best antibiotics available. Three units of blood were obtained from the district hospital in Ludewa, the total stock of blood in their facility, and transfused. She survived. A phone call to her village chairman asking for a relative to come to care for her was met with a comment suggesting it was known locally that she had attempted to abort her pregnancy.
The second was encountered in Amani dispensary, our furthest outreach clinic, on Friday. A 46 year old woman bleeding profusely who had ultrasound echoes in her uterus but not typical of incomplete abortion. It may have been malignant disease or endometrial hypertrophy. We had no facilities to treat her there and dare not risk making the haemorrhage worse by interfering.
At the end of a busy day we returned to Milo with three patients and one relative, a rather rough ride in the dark. Our headlights began to flash on and off until they went out completely and we drove slowly into Ludende village with the aid of a torch. The village was also in darkness due to a power outage. Fiddling with some electrical components under the bonnet solved the issue and, after buying lemons and a bottle of wild honey, we continued safely to Milo.
Our bleeding patient sat down in the ward entrance unable to walk further. Whether car sickness or fatigue was unclear. She was put to bed with iv fluids running and in the morning MVA was done. It became obvious then that she had been pregnant. Before this discovery was communicated with her family, her husband said she needs a BTL (tubal ligation). It seems likely he knew that she was pregnant, information that had not been disclosed when she attended with heavy bleeding. Very likely another unsafe abortion attempt. Not so close to death’s door as the first woman.
Both patients will have reliable contraception before leaving for home, progesterone implant for one and BTL for the other.
Whatever our views on pregnancy termination we cannot be impassive to the plight of women driven to such desperate and dangerous measures.
Moon and Jupiter rising some hours before the partial lunar eclipse of 28 October
The eagerly awaited lunar eclipse, maximal at 11.30 pm in Tanzania, was an anti-climax. We have clear skies most nights so visibility was no issue. However, only a minor bite was taken from the top right corner, far short of the Microsoft Apple.
Already one month has passed and we have been in the village 3 weeks. Today Noah sprayed the whole garden with pesticide so there will be no salad, no Guinea pig food and no rhubarb crumble for a week. Up to now Noah was only using water…
We have been on outreach to Lipangala, Ludende and Maholong’wa and seen many antenatal and other patients including some who are now old friends – Eliza delighted with her bouncing baby boy after successful treatment for infertility due to polycystic ovaries, Grace with her child and no sign of recurrence after removal of a massive ovarian mucinous cystadenoma. Sadly Grace’s husband is still in a leg plaster after external fixation of a fracture almost 3 years ago following a motorbike accident. He now has non-union and osteomyelitis, both significant risks with this type of treatment in this context. A hole in the plaster allows drainage of pus from sinuses. I fear an amputation maybe necessary.
Saturday we visited our friend Casimir the school teacher who visited us in North Wales in 2017 to gain experience and ideas from our UK education system. Luana is on the valley near Ludewa and very hot, 32 degrees. The car was also hot and began producing black exhaust fumes. On the return journey it struggled up the steep mountain road losing power and producing clouds of black and white smoke before dying. We were recovered and towed by the hospital car which carried a political slogan on its rear facing spare wheel cover, ironically reading TwendePamoja, ‘Let’s travel together’. We had little choice about that!
Sunday we entertained the village priest, his wife and 12 year old daughter Ruth (her older brother is Boaz) to tea and lemon cake. After supplying his wife with reading glasses (her first pair was stolen) we told them the story of Godly Play teaching in the nursery school. The teaching had to stop when a government edict appeared demanding that employed health sector staff must always be in their workplace, not off on some other business. That’s all very well, but at various times in the farming year there is much to be done in the fields and oft times rural staff will be called to hospital from ploughing, planting or harvest. No more it seems. No more teaching in Nursery School, Friday lunchtimes. Hopefully Godly Play can be relaunched on Sunday afternoons and the priest can pave the way.
In the hospital there has been a variety of medical and surgical cases. Caesarians for obstructed labour, breech presentation, fetal distress, twins, antepartum haemorrhage and the usual repeat operative deliveries. One vacuum extraction for a 4.5 kg baby in a first time mother. Advanced cancer of the cervix, laparotomy for suspected appendicitis finding instead pus in the right fallopian tube. A small baby with sepsis, jaundice and high temperature not responding to treatment. A 39 year old lady who has never menstruated seeking help with fertility. Plenty of challenges.
News from home of the death of a dear friend Suzy a few months after celebrating her 70th birthday. Despite illness of body and mind she smiled constantly, greeted cheerfully and enthusiastically, spread happiness and encouragement liberally and remembered everyone’s name, birthday, relatives and all. As I imagine her face to face meeting with the Jesus she loved and the conversation between them, I smile too. She always referred to me as her god-brother (as we are godparents to the same family) and the archangel Adrian (the reason of which is obscure except that she had a rather low opinion of herself and a high opinion of others). Many will miss her…
Suzy with Bishop Matthew and wife Scola of the Diocese of South West Tanganyika on their visit to Christ Church, Bala, 2017
The views expressed in this blog are the author’s own and do not necessarily reflect those of VSO, RCOG, Anglican Church in Tanzania or St Luke’s Hospital.
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